Infection Prevention and Control Guidelines: Community Health Docs/FNIHB AB Comm… · MRSA...

Infection Prevention and Control Guidelines: Community Health

First Nations and Inuit Health Branch – Alberta Region

Original: October 2011

Updated: January 2017

Infection Control Guidelines


January 2017 2

The 2011 version of this document was adapted from PICNet Infection Control

Guidelines: Providing Health Care to the Client Living in the Community: August 1, 2009

with permission from the Provincial Infection Control Network of British Columbia.

The PICNet 2014 document: Infection Prevention and Control Guidelines for Providing Healthcare to Clients Living in the Community, was used during the revision of this document along with the following resources:

Alberta Health:

Public Health Notifiable Disease Management Guidelines;

MRSA Guidelines, Hand Hygiene Strategy

Tuberculosis Prevention and Control Guidelines for Alberta

FNIHB AB Region:

Communicable Disease Manual – located on OneHealth

Reprocessing Reusable Medical and Dental Equipment: Policy and Protocols. Updated 2015

Home and Community Care Program Policy and Procedures manuals Health Canada:

A Guide for First Nations: Developing and Implementing a Facility Operations and Maintenance Management Plan (2010)

Transportation of Dangerous Goods: Nurses’ Training Manual (2014)

PHAC: Hand Hygiene Practices in Healthcare Settings (2012)

PHAC: Routine Practices and Additional Precautions (1998 and 2012)

Government of Nunavut

Nunavut Health, Infection Prevention and Control Manual (2012)

Public Health Ontario

Provincial Infectious Disease Advisory Committee (PIDAC): o Routine Practices and Additional Precautions o Environmental Cleaning for Prevention and control of Infections, 2012 o Infection Prevention and Control for Clinical Office Practice, June 2013 o Best Practices for Cleaning, Disinfection and Sterilization of Medical

Equipment/Devices in All Health Facilities, 3rd edition, 2013.



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Table of Contents

Working group members ............................................................................................................................................ 5

Abbreviations ............................................................................................................................................................... 6

1.0 Introduction ........................................................................................................................................................... 7

1.1 Purpose and Scope .............................................................................................................................................. 7

2.0 General Information About Infections ................................................................................................................ 8

Table 1 Common Clinical Signs of Infection ....................................................................................................... 8

2.1 The Chain of Infection ......................................................................................................................................... 9

Infectious Agent: ................................................................................................................................................. 9

Reservoir and Source of Infection: .................................................................................................................. 9

Portal of Exit: ..................................................................................................................................................... 10

Method of Spread: ............................................................................................................................................ 10

Portal of Entry: .................................................................................................................................................. 11

Susceptible Host: ............................................................................................................................................. 11

Interruption of the Chain of Infection ............................................................................................................. 12

3.0 Routine Practices ................................................................................................................................................. 12

3.1 Point of Care Risk Assessment .......................................................................................................................... 12

3.2 Hand Hygiene .................................................................................................................................................... 13

3.3 Source Control .................................................................................................................................................. 15

3.3.1 Early Identification, Diagnosis and Treatment of Infection ............................................................... 15

3.3.2 Respiratory Hygiene/Spatial Separation ............................................................................................. 16

3.3.3 Client Immunizations ............................................................................................................................. 16

3.4 Personal Protective Equipment (PPE) .............................................................................................................. 17

Table 2 Determining the Appropriate Mask ............................................................................................................ 19

3.5 Aseptic Techniques ............................................................................................................................................ 20

Injection safety procedures include: .............................................................................................................. 21

3.6 Sharps Safety and Prevention of Bloodborne Pathogen Transmission ............................................................. 21

Medications and Safe Administration and Storage of Injectables ............................................................. 21

Safe Handling, Transportation and Disposal of Sharps ............................................................................. 21

3.7 Management of Client Care Environment ......................................................................................................... 23

Client Care Equipment and Supplies ............................................................................................................ 24

Supply Bag/Container ...................................................................................................................................... 24

Personal Care Supplies................................................................................................................................... 25

Client Records .................................................................................................................................................. 25

Environmental Cleaning .................................................................................................................................. 26

3.8 Cleaning, Disinfection and Sterilization of Reusable Medical or Dental Equipment ....................................... 27

3.9 Handling of Linen.............................................................................................................................................. 27

3.10 Waste Disposal ................................................................................................................................................ 28



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3.10.1 Recommendations for Biomedical Waste Handling ........................................................................ 28

Table 3 Types of Waste............................................................................................................................................ 29

4.0 Additional Precautions ........................................................................................................................................ 30

4.1 Contact Precautions .......................................................................................................................................... 30

4.2 Droplet Precautions .......................................................................................................................................... 31

4.3 Airborne Precautions ........................................................................................................................................ 31

5.0 Laboratory Specimens......................................................................................................................................... 32

5.1 Collecting Specimens ........................................................................................................................................ 32

5.2 Transportation of Specimens ............................................................................................................................. 32

6.0 Food Safety ........................................................................................................................................................... 33

6.1 Food Safety Tips ............................................................................................................................................... 33

7.0 Pests and Infestations .......................................................................................................................................... 34

8.0 Healthy Workplace Strategies/Occupational Health ........................................................................................ 35

8.1 Immunization ..................................................................................................................................................... 35

8.2 TB screening for Health Care Workers ............................................................................................................. 36

8.3 Blood and Body Fluid Post Exposure Protocol ................................................................................................. 36

8.4 Respiratory Protection Program ....................................................................................................................... 37

8.5 Education and Training .................................................................................................................................... 37

9.0 Outbreak Management ....................................................................................................................................... 38

Definitions .................................................................................................................................................................. 39

Appendices ................................................................................................................................................................. 42

Appendix 1A: Hand Hygiene- Alcohol Based Hand Rub ........................................................................................ 43

Appendix 1B: Hand Hygiene- Hand Washing ......................................................................................................... 45

Appendix 1C: 5 Moments of Hand Hygiene ............................................................................................................ 47

Appendix 2A: Donning PPE .................................................................................................................................... 49

Appendix 2B: Doffing PPE ..................................................................................................................................... 50

Appendix 3A: Glove Use ........................................................................................................................................ 51

Appendix 3B: Mask Use .......................................................................................................................................... 53

Appendix 4: Admission Risk Assessment ................................................................................................................. 55

Appendix 5: Transportation of Dangerous Goods, Fact Sheet for Road Transport of Sharps as A Carrier .......... 56

Appendix 6: Environmental Cleaning ..................................................................................................................... 57

Appendix 7: FNIHB Alberta Region: Single Use Policy, January 14, 2014 .......................................................... 71

Appendix 8: Providing Care in Bed Bug Infested Residences ................................................................................. 74

References .................................................................................................................................................................. 76



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Working group members First Nations and Inuit Health Branch, Alberta Region would like to acknowledge the contribution and expertise of the Regional Infection Control Advisory Team members who reviewed and participated in the original adaptation of the Provincial Infection Control Network of British Columbia document and this subsequent update. See current PICNet document for more information about the process PICNet used in the development of their documents and

background resources. https://www.picnet.ca/guidelines/hcc/

FNIHB AB Region: 2017 Regional Infection Control Advisory Team

Ruth Richardson Regional CDC Nurse Manager, Chair

Fiona Jakielaszek Manager Accreditation, Patient Safety and Quality

Improvement

Pam Tailfeathers Buffalo Nurse Practice Consultant, Home and Community Care

Shirley Bourdouleix Regional Nurse Educator

Christina Smith Practice Consultant, Public Health

Randy Williamson NIHB Dental

Brenda Reid Dental Health Practitioner

Marcy Iwanyk: Environmental Health Officer

Wadieh Yacoub Director, Health Protection; Medical Officer of Health

Bill Weeks Secretariat, Health Protection

FNIHB AB Region: 2015 Regional Infection Control Advisory Team


Fiona Jakielaszek Nurse Manager Operations (Regional Nursing)

Pamela Tailfeathers Buffalo Regional Home Care Practice Consultant (and team)

Randy Williamson NIHB Dental

RoseMarie Kokotailo Community Dental Health Practitioner (retired but

contributor to updating manual)

Candace Fraser Regional Infection Prevention and Control Project

Manager/EHO (primary lead in updating document)

Wadieh Yacoub Director, Health Protection; Medical Officer of Health

Bill Weeks Secretariat – Health Protection

FNIHB AB Region: 2011 Regional Infection Control Advisory Team:


Fiona Jakielaszek Nurse Manager Operations (Regional Nursing)

Robin Cooper Nurse Practice Consultant - Home and Community Care

Christina Smith CDC Project Nurse, Community Health Nurse

RoseMarie Kokotailo Community Dental Health Practitioner

Candace Fraser Environmental Health Officer

Wadieh Yacoub Director, Health Protection, Medical Officer of Health

Bill Weeks Secretariat – Health Protection

https://www.picnet.ca/guidelines/hcc/



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Abbreviations

ABHR/AHR: Alcohol Based Hand Rub

AHW: Alberta Health and Wellness

APIC: Association for Professionals in Infection Control and Epidemiology

ARO: Antibiotic Resistant Organism

CCDR: Canada Communicable Disease Report (PHAC)

CDC: Centers for Disease Control and Prevention (Atlanta)

CSA: Canadian Standards Association

DIN: Drug Identification Number

FNIHB: First Nations and Inuit Health Branch, Alberta Region

GI: Gastro-intestinal

HCW: Health Care Worker/Provider

HIV/AIDS: Human Immunotropic Virus/Acquired Immune Disorder Syndrome

MOH: Medical Officer of Health

MMWR: Morbidity and Mortality Weekly Report (CDC)

MRSA: Methicillin Resistant Staphylococcus aureus

OHS: Occupational Health and Safety

PHAC: Public Health Agency of Canada

PPE: Personal Protective Equipment

SARS: Sudden Acute Respiratory Syndrome

TB: Tuberculosis

VRE: Vancomycin Resistant Enterococcus

WHMIS: Workplace Hazardous Materials Information System



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1.0 Introduction A systematic approach to infection prevention and control requires that each health care provider play a vital role in protecting everyone who utilizes the health care system, in all of its many forms: pre-hospital settings, hospitals, clinics, offices, home care and community programs, etc. Health care providers need to follow infection prevention and control practices at all times and use critical thinking and problem solving in managing clinical situations.1

Health care provided in the community or home setting is multidisciplinary. It includes, but is not limited to, care provided by nurses, community dental practitioners, community support workers (may include community health representatives, health care aides, maternal child workers, homemakers, etc.), dieticians, social providers, speech therapists, occupational therapists, physiotherapists, and visiting professionals.

Trends in health care have seen many changes that have shifted pressure onto community care givers. Early hospital discharge, increased age and acuity of discharged clients, increasing associated chronic illnesses and lifestyle factors are some of the challenges home health care providers face. New technologies and treatments have permitted clients to live longer in the community with health care provided in their communities. These teams are providing are increasingly more complex and more invasive care, such as intravenous therapy, hemodialysis, wound care, or ventilator therapy. These changes bring about increasing opportunities for transmission of infection.2

There is little evidence to suggest that the provision of healthcare in the home setting results in substantial disease transmission. Most infections in this setting are related to procedures and devices such as urinary or intravascular catheters. Risks of transmission mainly relate to hand hygiene and aseptic practices of the caregiver; cleaning and disinfection of equipment and supplies used between clients; and environmental cleanliness.

1.1 Purpose and Scope This document is intended to provide staff working in, or out of, health centres in First Nation Communities in Alberta with guidance pertaining to infection prevention and control practices within their community. Regional Nursing, Home Care, and Dental programs have developed policies and procedures based on the principles in this document relevant for the services provided within their respective program areas. This document does not address guidelines for private physicians’ offices, or private clinics. Physicians, dentists and other external contractors/ providers will be required to follow guidelines set out by their governing professional body or at a minimum, to conform to the infection prevention and control guidelines in this document.

The client, resident, or individual receiving health care, for the purposes of this document, will be referred to as the ‘client’ throughout. The types of settings covered by this document include health centres, nursing stations, client’s homes, schools, daycares, and ambulance/ transportation contexts where health centre staff is providing the service.

At the end of each section, references are provided for additional information and available resources in addition to the references cited throughout the document. All website links were

updated March 2016.



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2.0 General Information About Infections Microorganisms are very much a part of our world. They perform a variety of essential functions and interact with every living creature. The majority of microorganisms do not cause illness. There are several categories of microorganisms including: bacteria, viruses, fungi, and parasites. Some of these microorganisms are more pathogenic (likely to cause disease) than others. However, if conditions are favourable, many microorganisms are capable of causing disease in humans. An infection is an invasion of the body by microorganisms that multiply and cause an interaction between the host and the organism. Usually when an individual develops an infection they will show signs and symptoms such as fever, vomiting, diarrhea, and/or cough. In some instances, the interaction between the individual and the microorganism may only be a detectable immune response such as a tuberculosis (TB) skin test conversion (subclinical infection).3 In health care settings, infections are generally categorized into whether the person likely acquired the infection from his or her interaction with health care, or whether it was acquired from the community.

Community associated infection: An infection that is acquired before admission to hospital or is incubating at the time of admission.

Health care associated infection: An infection acquired during the course of receiving any type of treatment for other conditions, or that a health care worker acquires while performing their duties within a health care setting.

Nosocomial infection: An infection that develops during hospitalization or after discharge as a direct result of hospitalization.

Table 1 Common Clinical Signs of Infection

Inflamed Skin Skin that is red, hot, swollen, or has a rash

Fever or chills Temperature above 38°C*

Pus Green or yellow drainage or discharge from a wound or body cavity

Nausea or Vomiting Unexplained by change in diet, medications, etc.

Diarrhea Persistent or copious loose bowel movements, unexplained by diet or medication

Pain Sore throat or other pain, also pain that is disproportionate to severity of injury

Cough Productive, persistent or new cough

Painful Urination Painful and/or frequent urination

* For the elderly, infants or those taking an immunosuppressant medication, a temperature change may be subtle,

no change or higher or lower. Often for the elderly, the first indication of an infection may be a change in their cognitive abilities.

3



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2.1 The Chain of Infection Because microorganisms can, in some circumstances, threaten our health, control measures have been developed to inhibit their spread. These control measures are based on knowledge of the six main factors that influence the spread of microorganisms. These factors are collectively known as “The Chain of Infection”. The individual links of the chain of infection are explained below:

Infectious agent

Reservoir

Sus

cept

ible h

ost

Method of spread

Portal of entry P

orta

l of e

xit

Body excretions

Coughing/sneezing

Equipment

Breaks in skin

Breathing, swallowing

Mucus membranes

Invasive procedures

Sexual activity

Direct or indirect contact (person to person or contaminated object to person)

Common vehicle – contaminated food, blood, medication, instruments

Airborne

Vectorborne – insects, bats, ticks

Elderly, Young,

Immunocompromised Contaminated objects

Stagnant water

People

Animals

Bacteria, Viruses, Parasites

Chain of Infection

Adapted from APIC4

Infectious Agent: Each microorganism that causes human infections has characteristics that influence its ability to cause an infection. These include the number of organisms required to cause infection, ability of the organism to cause disease, ability of the organism to breech natural barriers, ability to survive in the environment, and ability to develop resistance to antimicrobials.3

Reservoir and Source of Infection: All microorganisms have both a reservoir and a source. These may be the same or different. A reservoir is the place where the organism maintains its presence, metabolizes and replicates. Reservoirs of infection include: people (both healthy and ill), animals, or inanimate objects. A source is the place from which the microorganism passes to the host. Sources may be animate or inanimate.



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Portal of Exit: The exit of the pathogen is dependent on the location of the microorganism in the body. Microorganisms can be expelled from the respiratory tract during breathing, coughing or sneezing, and from the gastrointestinal tract (GI) via saliva, emesis, feces or drainage from sites within the GI tract. Urine, blood, genital secretions and drainage from wounds may also carry microorganisms out of the body. Hepatitis A or norovirus, for example, exits the body via the GI tract and can be transmitted through vomiting, diarrhea, and/or improperly washed hands after toileting.3

Method of Spread: Microorganisms can be transmitted from their reservoir or source to a susceptible host by several routes3:

Direct Person to Person Contact - This is the most common mode of transmission and can occur through skin to skin contact, especially from one’s hands following sneezing or coughing or following contact with an open wound.

Indirect Contact - Hands pick up organisms from contaminated surfaces or equipment and then inoculate the individual or transmit the organisms to others.

Droplet Contact - This involves exposure of the mucus membranes of the conjunctiva, nose and mouth as a result of sneezing or coughing by an infected person. These droplets are heavy and usually travel no more than approximately two metres (six feet) before falling to the ground.

Airborne Transmission – This occurs by dissemination of an infectious agent either by droplet nuclei or tiny particles in the air. The agent can be widely dispersed by air currents and remain suspended in the air for extended periods of time (hours), enabling it to be inhaled.

Common vehicle – A contaminated inanimate vehicle such as food, water, or blood products may serve as a passive vector for transmission or even allow the microorganism to multiply within them.

Vectors – Vectors (i.e. mosquitoes, flies and bats) carry microorganisms as part of their normal flora, or as an infection, and may infect humans through a bite.

Some microorganisms have single routes of transmission (e.g. TB) while others have two or more routes (e.g. influenza, measles, salmonella).3



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Figure 1: Method of Spread

Contact Transmission

from Hands (Direct) or Objects (Indirect) Droplet Transmission (up to 2 metres) from Coughing or Sneezing

Airborne Transmission (> 2 metres)

Vehicle Transmission

Vector-borne Transmission

Adapted from PIDAC5

Portal of Entry: These may be the same as the portals of exit. All of the portals have natural barriers that protect the body from microorganisms. The barriers are normally effective, but microorganisms may enter if the barriers are damaged, or if they have been compromised by invasive medical devices (e.g. catheters, feeding tubes).

Examples of portals of entry include the gastrointestinal tract where the infection is by ingestion, the urinary system via a urinary catheter, or the respiratory system where the infection is through respiration.

Susceptible Host: Humans have defense mechanisms to protect against infections. These include skin; mucous membranes; certain body secretions such as tears; inflammatory response; genetic, hormonal, nutritional and/or behavioural mechanisms; and personal hygiene.3 The same organism frequently produces different severity of illness in different individuals depending upon host mechanisms.

Occasionally, circumstances arise where the normal balance between microorganisms and their host is disturbed. This may be due to a disease process, altered immune status, extremes of age, invasive procedures, drug therapy, poor nutrition, irradiation, etc. Should the host develop an infection as a result of this disturbance, a new reservoir of microorganisms may be established, thus further increasing the risk of infection to other people.



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Interruption of the Chain of Infection By understanding the basic roles and functions of microorganisms in our environment, principles can be applied to interrupt the chain of infection. Good personal hygiene and proper handling of body excretions and secretions cannot be over-emphasized. Diligent hand hygiene remains the single most important element in controlling the spread of infections. Attaining target immunization coverage rates remains the single most important element in the preventing vaccine preventable infections.6,7 Preventing infections is everybody’s business.

3.0 Routine Practices Routine practices is the term used by Public Health Agency of Canada2 to describe the system of infection prevention and control practices used to prevent the transmission of infections in health care settings. Routine practices should be used with all clients at all times.

Close attention to routine practices is fundamental to preventing transmission of microorganisms from client to client, client to staff, staff to client, and staff to staff in all health care settings.

The basic elements of routine practices include2:

Point of Care Risk Assessment (PCRA)

Hand Hygiene

Source Control

Client placement, accommodation, and flow (not addressed in this document)

Use of personal protective equipment (PPE)

Sharps safety and prevention of bloodborne pathogen transmission

Management of the client care environment o Cleaning of the client care environment o Cleaning and disinfection of non-critical client care equipment o Handling of waste and linen

Education of Clients

3.1 Point of Care Risk Assessment Point of Care Risk Assessment (PCRA) is one of the key components of routine practices. It is a method of assessment conducted by the caregiver that must be done at each interaction with the client or their environment to determine potential risks associated with providing care, as well as the implementation of risk reduction strategies or interventions to minimize exposure to these hazards. The current Infection Prevention and Control Guidelines by the Public Health Agency of Canada2 emphasize doing point of care risk assessments throughout the spectrum of care, as a critical element of infection prevention and control. Routine practices and additional precautions and their application are based upon the PCRA. A PCRA assesses the variables related to the interaction between the health care worker (HCW), the client, and the client’s environment to assess the potential for exposure to infectious agents and identify risks for microorganism transmission. This includes the care that is going to be provided by the HCW, individual client characteristics, and the condition of



January 2017 13

the environment. A PCRA should be done prior to the care of all clients, at all times, across the continuum of care, by all health care workers.

Based on the assessment, implementation of additional precautions including proper use of personal protective equipment is essential to protect both staff and the client.

Resources

FNIHB AB: Point of Care Risk Assessment

3.2 Hand Hygiene Hand hygiene is most effective infection control measure to prevent the spread of infections and includes:

Hand washing: which is the physical removal of soil and transient microorganisms from the hands using mechanical action or scrubbing with soap and water

Hand antisepsis: is the use of an antiseptic agent such as Alcohol Based Hand Rub (ABHR) or antiseptic soap to decontaminate and disinfect the hands.

Hand health: actions taken to maintain healthy hands and fingernails

The Public Health Agency of Canada revised the standard of care for hand hygiene in 2012, to require use of Alcohol Based Hand Rub (ABHR) for hand hygiene by all health care workers across all healthcare settings. Use of ABHRs reduce bacterial counts on the hands of healthcare workers (HCWs) markedly better than washing hands with plain soap and water, and are as or more effective than handwashing with an antiseptic soap.6

Alcohol Based Hand Rubs should be used as the standard practice for all HCWs with the following exceptions:

when hands are visibly soiled with organic material, or

if exposure to norovirus and potential spore-forming pathogens such as Clostridium difficile is strongly suspected or proven, including outbreaks involving these organisms.

Five Moments Of Hand Hygiene

When providing care there are at minimum five moments of hand hygiene that can be applied in all heath settings for protecting the health care worker and the client from exposure to harmful bugs:

1. Before touching the client 2. Before performing clean or aseptic procedures 3. After exposure to blood or body fluid and after glove removal 4. After touching the client 5. After touching the client surroundings



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Hand Health

Since intact skin is the first line of defense for microorganisms. Damaged skin and painful cracked hands and cuticles may shed microorganisms and negatively impact workers adherence to hand hygiene. Attention to maintaining healthy skin and nails to prevent breakdown is required. Regular use of a hand lotion or moisturizing products such as barrier creams is recommended. Care givers with open lesions on their hands should apply an air and water tight bandage before starting work and/or use gloves when in direct contact with any client. If the lesion cannot be covered with either a bandage or gloves, reassignment may be considered until the lesion heals6.

Clients and Hand Hygiene

Hand hygiene is not only important for the health care workers but also clients:

Clients who are able to participate in self-care should be taught, encouraged and reminded of the importance of hand hygiene before eating or preparing food, after using the toilet or other personal hygiene activities, before leaving their homes for common/public areas and when returning home from public places.

Clients who are unable to assume responsibility for self-care should be assisted in performing hand hygiene whenever their hands are soiled or may be contaminated, and as recommended above.

Resources:

FNIHB AB Region:

Hand Hygiene References and Resources o Appendix 1A: Hand Hygiene – Alcohol Based Hand Rub o Appendix 1B: Hand Hygiene – Hand Washing o Appendix 1C: 5 Moments for Hand Hygiene – community care and dental care

Alberta Health:

Infection Prevention and Control Strategy, updated 2015 Alberta Health Services

Hand Hygiene Policy

How to Hand Wash

How to Use Alcohol Based Hand Rub Public Health Agency of Canada:

It’s Your Health: The Benefits of Hand Washing

Hand Hygiene Practices in HealthCare Settings World Health Organization

Your Moments of Hand Hygiene

http://www.health.alberta.ca/documents/IPC-Alberta-Strategy-2015.pdf

https://extranet.ahsnet.ca/teams/policydocuments/1/clp-hand-hygiene-ps-02-policy.pdf

http://www.albertahealthservices.ca/assets/Infofor/hp/if-hp-ipc-flu-handwash-how-to.pdf

http://www.albertahealthservices.ca/info/Page11362.aspx

http://www.hc-sc.gc.ca/hl-vs/iyh-vsv/diseases-maladies/hands-mains-eng.php

http://publications.gc.ca/collections/collection_2012/aspc-phac/HP40-74-2012-eng.pdf

http://www.who.int/gpsc/5may/residential-care.pdf



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3.3 Source Control Source control measures are used to contain organisms and prevent them from being spread from the infectious source. In the community environment, source control measures include:

Early identification, diagnosis and treatment of infection

Respiratory hygiene (cough etiquette)

Hand hygiene

Spatial separation for symptomatic clients

Up to date immunizations

Safe handling of sharps

3.3.1 Early Identification, Diagnosis and Treatment of Infection Any client receiving health care services in the community may carry potential risks for

introducing and transmitting infections within the service; from client to health care

worker (HCW), from HCW to client, or from client to client. Early identification through

employing a Point of Care Risk Assessment (PCRA), in conjunction with education for

the client and family, is an essential component of infection prevention and control in the

community.2,9

It is important for the health care provider to keep in mind that the information on the referral or authorization form may not present the complete picture. Depending upon the intake process for new Home Care clients there may be two opportunities to perform a risk assessment:

1. While booking the initial appointment, questions regarding potential infectiousness should be asked, such as whether the individual has a fever, cough, rash or vomiting/diarrhea. This risk assessment should be ongoing for all interactions.

2. During the admission process, a more complete health history is performed by using information from the person’s intake form, or other documentation as well as interviewing the client.

Resources:

FNIHB Alberta Region:

Appendix 4: Admission Risk Assessment

Tuberculosis Program Screening Algorithms

Home and Community Care admission procedure

Point of Care Risk Assessment package Alberta Health:

Notifiable Disease Management Guidelines

Notifiable Disease Report Manual

http://www.health.alberta.ca/professionals/notifiable-diseases-guide.html

http://www.health.alberta.ca/documents/ND-Report-Manual.pdf



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3.3.2 Respiratory Hygiene/Spatial Separation There is potential for exposure to or transmission of respiratory organisms in any care setting. Personal practices on the part of clients and health care providers can help prevent the spread of the organisms that cause respiratory infections. These practices include:

Staying home when sick

Measures to reduce contact with droplets when coughing or sneezing, such as: o Turning head away from others o Keeping some distance from others (2 metre spacing) o Covering the mouth and nose

Immediate disposal of tissues after use

Immediate hand hygiene following use of tissues

A client with respiratory symptoms should wear a surgical mask - if they can tolerate wearing a mask - in all health care settings to minimize exposure of others to potential infection.

Resources:

Alberta Health Services:

Cover Your Cough

3.3.3 Client Immunizations Immunizations are the most effective method to reduce the potential for transmission of communicable disease in clients, staff and residents. Maintaining up to date immunizations for both the health care worker and client is essential.

Health care providers have a responsibility to ensure that clients under their care have protection against vaccine preventable diseases through appropriate immunization. All clients should be encouraged to discuss their immunization needs with the community health nurse and keep their immunization status current. For adults, the following immunizations are recommended:7

tetanus-diphtheria (Td) vaccine: a booster should be given every 10 years.

influenza vaccine (FLU): annual immunization is recommended for everyone 6 months of age and older, with a special emphasis on those at greatest risk from influenza disease complications to mitigate impact of influenza.

pneumococcal vaccine (PPV23): eligible individuals 2 to 64 years of age should receive one dose; individuals over 65 years of age should also receive a dose of polysaccharide vaccine, even if there is history of a prior dose.

Hepatitis B (HBV): see eligibility criteria.

Rubella and varicella: documentation of immunity or immunization (MMR, VZV)

Resources

FNIHB Alberta Region:

Immunization Section: vaccine program summary pages, routine schedule.

Annual Influenza Program

http://www.albertahealthservices.ca/Search.aspx?q=cover+your+cough&site=ahs-external&client=ahs-external&getfields=keywords%3Adescription&entqr=0&output=xml_no_dtd&filter=0&sort=date%3AD%3AL%3Ad1



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Public Health Agency of Canada:

Canadian Immunization Guide

National Advisory Committee on Immunization Statements (NACI)

3.4 Personal Protective Equipment (PPE) Using personal protective equipment (PPE) during provision of health care services is another strategy used to reduce risk of transmission of disease or exposure to hazards for staff and clients, by providing effective barriers when used properly. The point of care risk assessment determines the necessary PPE required to safely interact with clients.

Primary PPE includes:

gloves

gowns

masks

eye protection

PPE is only effective when used properly. All PPE is to be donned immediately prior to client interaction.

The highest risk for contamination occurs during PPE removal. Therefore, strict adherence to doffing protocol is required. Items must be removed and discarded immediately after the provision of care and shall not be worn outside of the client care area.

A sufficient supply of PPE should be available for all health care workers as required and in appropriate sizes.

Education in proper use of PPE is required for all health care workers who provide direct care or who have the potential for exposure to blood and body fluids.

Gloves

Touch is a fundamental part of human interaction and can be an important aspect of quality client care. Gloves are not needed for routine client care when the contact is limited to a client’s intact skin (i.e. assisting in bathing, taking a blood pressure, administering an immunization). Gloves are worn when it is anticipated that the hands will be in contact with non-intact skin, tissue mucous membranes, blood, body fluids, secretions, excretions or equipment or surfaces contaminated by the above. 2,8 Glove use is not a substitute for hand hygiene. When using gloves:

wear the appropriate type of glove for the task (see next section)

wear the correct size of glove

remove hand jewelry (jewelry reduces the effectiveness of thorough hand hygiene and can tear gloves)

perform hand hygiene before putting on and after removing gloves

do not wash gloved hands and re-use gloves

gloves must be changed between clients dispose into regular garbage (if disposable)

http://www.phac-aspc.gc.ca/publicat/cig-gci/index-eng.php

http://www.phac-aspc.gc.ca/naci-ccni/index-eng.php



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The type of gloves that are used should be selected is based on the given task. Gloves may be:

Sterile (surgical) gloves are worn to protect clients from contamination during an aseptic procedure. They also provide protection for the wearer. Use these gloves when performing a sterile procedure (i.e. inserting or changing a urinary catheter).

Clean (non-sterile) disposable gloves (single-use medical examination gloves – vinyl, latex or copolymer nitryl or nitrile) are worn to protect the wearer from sources of contamination. Use these gloves when touching blood or other body secretions and excretions, mucous membranes, undiagnosed rashes, or protecting the care giver’s skin if he or she is at risk due to non-intact skin such as dermatitis. Choose the appropriate glove to fit the specific task.

Non-disposable rubber gloves (i.e. rubber household gloves) are for tasks other than client care. Use these gloves to protect the hands from chemicals and detergent solutions while performing routine housekeeping. Rubber gloves used in the health centre are to be designated to specific individuals and should be cleaned after each use; i.e. one pair per individual. Rubber gloves used in the client’s home should be cleaned, and then left in the client’s home.

Gowns and Protective Apparel (i.e. Aprons)

The routine use of gowns and aprons for basic client care is not necessary. Gowns and/or plastic aprons should be worn as indicated by the PCRA where it has identified that a HCW’s clothing is likely to become soiled with spray or splatter, blood, feces, urine or any other secretions, or if significant contamination of the environment is occurring. Examples of need for gown use include:

Dealing with clients with uncontrolled diarrhea that cannot be contained with incontinence products and resident is not confined to bed

draining, infected wound in which dressing cannot reliably contain drainage

provision of foot care

dental procedures such as extractions Gowns or aprons should be used for specific clients only and disposed into regular garbage immediately after each use. Gowns/aprons must always be changed and hand hygiene performed between clients.

Lab coats are often used in practice but should not be consider as effective PPE against exposure to blood, body fluid, secretions or excretions. They are to be used as an alternative to uniforms to provide a protective barrier for the health care worker’s street clothes. A lab coat is intended for full-day use, removed when outside of client care area and are either discarded if disposable or laundered at the end of the work day or when visibly soiled.



January 2017 19

Masks and/or Other Face Protection (Goggles, Face Shield)

Masks are not often required in community settings. The science regarding respiratory protection is still evolving.

Health care providers should wear a mask that covers the mouth and nose, and goggles or a face shield during client-care activities when indicated by the PCRA and that are likely to cause airborne debris, splashes or sprays of blood, body fluids, secretions, or excretions onto the face. See the eye protection section for requirements re protection from splash and spray. Masks are selected based on the identified risks.2,8 This includes:

Surgical Masks

N95 Respirators

Table 2 Determining the Appropriate Mask

Mask Use Surgical Mask N95 Respirator*

Particle Size Filter to 5 microns (large droplets) Filters 95 % of Particles to 1 Micron (droplet

nuclei)

Why to Use Provide a physical barrier against respiratory droplet secretions

Provide a physical barrier AND filter against infectious respiratory particles

When to Use Wear as determined by the PCRA, when:

within two metres of a client with respiratory symptoms

performing activities that are likely to cause splashes or sprays onto the face

performing aseptic procedures

Wear as determined by the PCRA, when:

caring for individuals who require airborne precautions (measles, tuberculosis, SARS)

performing aerosol generating medical procedures (AGMP). i.e.: intubation and related procedures (e.g. manual ventilation, open endotracheal suctioning), cardiopulmonary resuscitation, sputum induction, nebulized therapy, non-invasive positive pressure ventilation14.

How to use Secure ties or ear loops

Extend mask to ensure full coverage of nose, mouth and chin

Mold nose piece to the bridge of nose

Fit Testing is required

Seal Check before each use

When to

Discard

Single use

Change mask if becomes wet, soiled or dirty.

Single use

Change mask if becomes wet, soiled or dirty.

*If a N95 respirator is considered necessary, fit testing is a requirement to ensure that the correct respirator type and size is

worn and that the wearer is taught how to do a seal check to ensure a proper facial seal each time the device is worn. Health care workers should only use the type of respirator for which they were successfully fit tested. Fit-testing should be done every two (2) years, or if there is significant weight fluctuation or changes to facial structure.



January 2017 20

Eye protection

Eye protection is used by the health care worker to protect the mucous membranes of the eyes when indicated by the PCRA and it is anticipated that care is likely to generate splashes or sprays of blood, body fluid, secretion or excretions or within two metres of a coughing client.

Eye protection includes:

Safety glasses

Safety goggles

Face shields

Visors attached to masks

Prescription eyewear does not provide adequate protection; therefore goggles or face shields that fit over eyewear must be worn whenever airborne debris, splashes or sprays are anticipated.

Eye protection may be disposable or reusable; if reusable, cleaning and disinfection is required before reuse.

Resources

FNIHB AB Region

Appendix 3A: Glove Use

Appendix 3B: Mask Use

Alberta Region Respiratory Protection Program

Alberta Health Services

Guide To Personal Protective Equipment

Donning (Putting on) Personal Protective Equipment poster

Doffing (Taking off) Personal Protective Equipment poster

Donning and Doffing video Canadian Committee on Antibiotic Resistance

Infection Prevention and Control Best Practices

3.5 Aseptic Techniques Aseptic techniques2 are measures designed to render the client’s skin, supplies and surfaces maximally free from micro-organisms. These practices are used when performing procedures that expose the client’s normally sterile sites (e.g. intravascular system, urinary tract) in order to keep them free from micro-organisms that could cause infection. Components of aseptic technique prior to a procedure involve the following:

Preparing the client’s skin with an antiseptic

Hand hygiene

Use of sterile gloves, gown, masks, equipment and drapes as indicated

Maintaining a sterile field


http://www.albertahealthservices.ca/hp/if-hp-ipc-donning-ppe-poster.pdf

http://www.albertahealthservices.ca/hp/if-hp-ipc-doffing-ppe-poster.pdf


http://www.wsava.org/sites/default/files/Infection%20Prevention%20and%20control%20Best%20Practices%20.pdf



January 2017 21

Common invasive procedures performed in community based care that require aseptic technique include initiating intravenous access, wound care, and insertion of urinary catheters. Infections (either local or systemic) may result from insufficient skin cleansing prior to injection of medications, vaccines or venipuncture. Aseptic technique for the withdrawal of medication or other sterile substances from any vial or other container includes: hand hygiene, the use of alcohol to clean the stopper or port, single-use sterile needles and syringes, and following manufacturer’s instructions. Transmission of Hepatitis B and Hepatitis C and other agents have been associated with the re-use of needles and/or syringes used to withdraw agents from multi-use vials, inappropriate use of glucose monitoring equipment, and reusing a single needle and syringe to administer medication to multiple clients.

Injection safety procedures include:

Do not administer medications from the same syringe to more than one client, even if the needle is changed

Consider a syringe or needle to be contaminated after it has been used to enter or connect to a client’s intravenous infusion bag or administration set

Do not enter a vial or bag/bottle with a used syringe or needle

Do not use medication packaged as single-use vials for more than one client

Assign medications packaged as multi-use vials to a single client whenever possible

Follow aseptic practices during the preparation and administration of injectable medications.

3.6 Sharps Safety and Prevention of Bloodborne Pathogen Transmission Sharps are objects that are capable of causing punctures or cuts to an individual. When a sharp has been in contact with blood, body fluids or exudates, there is the potential for exposure to bloodborne pathogens (Hepatitis B, Hepatitis C or HIV). All sharps must be handled in such a way as to keep them sterile until use, and then safely disposed of immediately following use to minimize any potential exposure.

Medications and Safe Administration and Storage of Injectables Blood borne pathogens may be transmitted to clients during the provision of health care

services due to unsafe or improper injection, infusion and medication vial practices.

Injectable medication must be5:

Administered using aseptic technique

In single dose format whenever possible

Stored as per manufacturer’s directions, i.e. biological fridge

Safe Handling, Transportation and Disposal of Sharps Safe handling, transportation and disposal of sharps (i.e. needles, scalpel blades, etc.)

minimize the risk of injury and exposure to bloodborne pathogens and is the

responsibility of the health care worker. Used sharps are considered biomedical waste

and must be transported and disposed according to provincial and federal requirements.



January 2017 22

Needles must not be recapped, purposely bent, broken, removed from a disposable syringe or manipulated by hand. o Do not uncap a needle unless there is an appropriate container accessible for

immediate disposal. o Use “point of use” disposal receptacles for sharps.

Sharps containers should be readily available in all areas of client care at the point of use. o Wall mounted units in clinic rooms are preferred as they are secured,

however special attention must be given to placement and ease of access.

Ensure that containers are safely placed in the client’s home, mobile clinic or other settings, to avoid injury or misuse. o Take into consideration presence of children, confused adults, IV drug

abusers, etc.

Sharps containers must not be over filled. o Most containers indicate a “fill line” at about the ¾ full mark, beyond which the

container should not be filled. Remove and replace sharps containers when the “fill line” is reached. Broken glass contaminated with body fluids may be disposed of in the

sharps containers.

Sharps containers for use off site will be transported by the health care worker and therefore must be puncture resistant, have a tight fitting lid that seals, and be clearly labelled.

Teach clients, their family members, friends or other care givers in the home the correct procedures for safe handling and disposal of sharps and sharp containers. o Full sealed sharps containers delivered to the health

centre by community members can be placed in the health centre’s Medical Waste Box for disposal.

Transporting of Sharps As a Carrier

A degree of precaution must always be taken with any sharp items. Sharps used in

direct patient care present an injury hazard to health care personal and waste workers.

Health care workers must follow Transportation of Dangerous Goods guidelines when transporting sharps in their vehicle10:

adequate training on the handling and transportation of dangerous goods has been received

a Certificate of Training has been issued and is current



January 2017 23

Sharps Disposal

Sharps must be disposed of as biomedical waste

Containers should be sealed when full. They should never be emptied or reused.

Place full sharps containers in a biomedical waste box that is lined with a biohazard bag.

The Biomedical Waste Box shall be stored in the designated biohazardous waste room that is appropriately signed and remains secured.

Once the waste box is full, the inner bag should be sealed with tape and the outer box should be taped closed.

Transportation of Medical Waste boxes for disposal must follow Transportation of Dangerous Goods Regulations for packaging, labelling and documentation.

Resources:

FNIHB Alberta Region

Appendix 5: TDG Fact Sheet

Public Health Agency of Canada

Laboratory Safety Office, 2014 Transportation of Dangerous Goods, Online Nursing Manual. (Accessed via Regional Nursing)

3.7 Management of Client Care Environment When providing care or services outside of the health centre11:

Limit the amount of equipment taken off site to only necessary supplies needed to perform care

Leave any equipment that can be dedicated to the client in the home. Client specific items should not be returned to health centre when no longer needed unless it is a reusable item that can be cleaned and sterilized.

Clean and disinfect any non-critical client care equipment (i.e. stethoscope) that cannot be left in the home using a low level disinfectant, before taking it from the home. Alternatively, place reusable items in a plastic bag for transport and subsequent cleaning3 upon return to the health centre.

Clean any reusable equipment used on the client prior to being reused. Place used items in a designated “dirty” container for transportation and storage until the item can be properly reprocessed.

Supplies should include appropriate personal protective equipment needed for routine practices and any assessed additional precautions (e.g. a box of disposable gloves, masks, plastic aprons, and hand hygiene supplies as per PCRA). o Health Care Workers may find it useful to leave a box in the client’s home

along with other necessary supplies. The box should be kept separate in a clean area and should be labelled “for Health Care Worker Use Only”.



January 2017 24

Client Care Equipment and Supplies Clients should be evaluated on a case-by-case basis to determine whether dedicated equipment is indicated. Use of single use (disposable) equipment is the standard of practice when available.

Limit the amount of reusable equipment that is brought into the home of clients who are infected or colonized with organisms such as methicillin resistant staphylococcal aureus (MRSA) or vancomycin resistant enterococcus (VRE).

Minimize supplies going into the home. Unused disposable supplies that have been left in the home with the client should be disposed of once the client is discharged from home care services, and should not be returned to the health centre.

If loaner equipment is dedicated to a client, it should be left in the home until the client is discharged from home care services. The equipment should be cleaned and reprocessed appropriately before use with another client. This would include items such as tub rails, aids to daily living, wheelchairs, commode chairs, etc.

Clean and disinfect any non-critical client care equipment (i.e. stethoscopes) that cannot remain in the home before leaving the home if possible. Otherwise, place reusable items in a plastic bag for transport to another site for subsequent cleaning and disinfection if necessary.

Reusable semi-critical or critical instruments used in the field, should be stored in a dedicated “dirty” container after use and returned to health centre for reprocessing.

Resources

FNIHB AB Region:

Section 5.10: Reprocessing Requirements

Appendix 6: Environmental Cleaning

Appendix 7: Single Use Policy

Reprocessing Medical and Dental Re-usable Equipment: Policy and Practices

Supply Bag/Container The supply bag/container is used to carry essential equipment (non-critical to critical) that is necessary for the provision of care outside of the health centre environment. It is important to maintain the supply bag/container in a clean manner and to establish a clean environment regardless of location, for the provision of care.

The health care provider’s supply bag/container should be made of material that is easily cleaned or washable. Bio-burden may accumulate on the exterior surface of the bag/container, therefore it should be cleaned and disinfected when visibly soiled or on a weekly basis. Clean the interior surfaces of the bag routinely (every three months) or as required.

Care providers should perform hand hygiene prior to reaching into the bag to obtain supplies.

Place the supply bag/container on a cleanable surface such as a table or non-absorbent chair. If general sanitation is a concern in the care environment, create a clean environment by disinfecting the surfaces with a disinfectant wipe or by



January 2017 25

placing a barrier such as an unused garbage bag underneath the supply bag/container. The supply bag/container can theoretically act as a vector for the transmission of organisms from one client’s home to another, therefore, care should be taken in the placement of the bag/container, as well as for the bag/container to be routinely cleaned and disinfected.

The supply bag/container should not be taken into dwellings that are infested with cockroaches, ants, rodents, or other vermin whenever possible. In this instance, only those products that would be used during the visit should be taken into the dwelling.

Inside the supply bag/container, semi-critical items should be kept covered and critical items should be contained in sterile wrappers that will prevent contamination until point of use.

Personal Care Supplies Personal Care supplies pertain to those items used for elements of a person’s routine care such as:

bathing

skin care

nail care

oral care and denture care

hair care

It is important that personal care supplies are not shared and are kept clean. This can prevent the transmission of infection or infestations (i.e. conjunctivitis, MRSA, lice, scabies).

Ideally, clients should have their own soaps, lotions or creams, toothbrush, toothpaste, denture box, comb, hairbrush, nail file, nail clippers, shaver (electric or disposable), and bath towel. These items should not be shared with others, including family members.

Toiletries supplies used or supplied at the health centre should be single-use or dispensed in a manner which does not contaminate the bulk container.

Bath towels or other linens should not be shared and should be laundered after use.

Client Records

Do not take the client record into an area where contamination is likely to take place.

Perform hand hygiene between client contact and documentation.

Medical records are confidential and must be maintained in a secure manner.



January 2017 26

Environmental Cleaning

Health Care Facilities

The environment is a reservoir for infectious agents especially in settings where there are ill clients that are coughing, sneezing, incontinent, vomiting or having diarrhea. Bacteria and viruses may survive on surfaces for extended periods of time and be transmitted to other susceptible clients or residents. Cleaning alone, will not destroy these unwanted organisms.

Cleaning removes any visible organic debris or foreign material from the surface. Cleaning involves use of water, detergents and mechanical action to remove debris. The mechanical action of cleaning reduces the microbial load on the surface through physical removal.

Disinfection is the inactivation of disease-producing microorganisms. It does not destroy bacterial spores. Disinfection is dependent on several factors including: effective pre-cleaning; concentration, contact time, and amount of disinfectant applied to the surface etc.

Environmental cleaning is one of the most important steps in breaking the chain of infection. Environmental cleaning consists of 12 :

Routine cleaning followed by disinfection of health facility using hospital grade disinfectants

Additional cleaning and disinfection of high touch surfaces, medical equipment and devices, hydrotherapy tubs, blood and body fluid spills or in outbreak situations

Education for janitorial staff

Auditing and review of cleaning practices

Household Facilities

Consistent, regular cleaning assists in reducing the potential for environmental transmission of microorganisms. Although the requirements are more stringent in a health care setting, cleaning and disinfection of high touch surfaces or areas that are heavily soiled or contaminated in the home is also important.

Encourage clients and their care givers to perform regular cleaning of frequently touched surfaces (i.e. taps, sinks, toilets, bedside tables) as one way to prevent the spread of infection to others in the home.

If there is illness in the home, (e.g. individuals with respiratory or gastrointestinal symptoms), increased cleaning and disinfection is recommended. Good hand hygiene practices are also important in reducing the spread of germs.

Housekeeping routines should involve cleaning followed by disinfecting of surfaces, toys and objects with a household low level disinfectant using the correct concentration and contact time as indicated on the label instructions.



January 2017 27

Resources

FNIHB AB Region:

Appendix 6: Environmental Cleaning FNIHB National:

Environmental Training Guide; Modules.

American Cleaning Institute:

Clean Living at Home

Hard Surface Cleaning Fact Sheet

3.8 Cleaning, Disinfection and Sterilization of Reusable Medical or Dental Equipment The level of reprocessing required for reusable dental and medical equipment is

determined by the classification of the item according to the level of risk of infection, as

indicated by the Spaulding Level of Classification13. Medical and dental equipment are

classified into three groups:

Non critical o devices that touch only intact skin not mucous membranes or do not come in

direct contact with the client. Cleaning followed by low level disinfection is required at minimum.

Semi critical o devices that come in contact with non-intact skin or mucous membranes but

usually does not penetrate them. At minimum cleaning followed by high level disinfection is required

Critical o devices that enter sterile issues including the vascular system. They present a

high level of risk of infection if the devices is contaminated and cleaning followed by sterilization is required

Resources

FNIHB AB Region: For detailed policy and procedures regarding cleaning, disinfection and sterilization of reusable medical and dental equipment refer to:

Reprocessing Reusable Medical and Dental Equipment Policy and Protocols

Instructional Manual for Reprocessing Reusable Medical and Dental Equipment

3.9 Handling of Linen Microbial counts on soiled linens are significantly reduced during mechanical action and dilution of washing and rinsing. With the high cost of energy and use of cold water detergents (which do not require heat to be effective), hot water washes may not be necessary. There are several studies that show low temperature laundering will

http://www.cleaninginstitute.org/clean_living_at_home/pdf

http://www.cleaninginstitute.org/assets/1/Page/Hard_Surface_Hygiene.pdf



January 2017 28

effectively eliminate residual bacteria to a level comparable to high temperature laundering.16, 17

Linens used in the health care setting can be laundered together using detergent, and dried in a hot air dryer to ensure killing of microorganisms. Linens soiled with large quantities of organic material (i.e. stool or vomitus) will require pre-treating to remove the material. It is impossible to clean laundry when organic material is present. Although soiled linen has been identified as a source of microorganisms, the risk of actual disease transmission appears low, provided that hygienic handling, storage and processing of clean and soiled linen are carried out.

Clean laundry must be stored apart from soiled linens. Health care providers should handle any laundry soiled with blood or body fluids with gloves and avoid touching it to their clothes or skin; position the laundry basket nearby to reduce handling (keep off the floor and upholstered furniture); handle with minimal agitation and do not shake; remove fecal material into the toilet. Teach family or care givers how to handle contaminated laundry safely. Wash heavily soiled laundry separately and add bleach to wash water according to the manufacturer’s instructions if material is bleach tolerant. Hand hygiene is required when task is complete.

3.10 Waste Disposal It is important that all waste be disposed of safely and properly. Usually, waste generated in health care settings is no more hazardous than general household waste. Non-biomedical waste, such as general office waste, used gloves or non-sharp medical equipment, requires no special handling other than containment during disposal and removal. Dressings or waste that is soaked with blood or body fluids should be bagged prior to placing into the garbage.

There are certain items that must be treated as biomedical waste, in accordance with local, regional, provincial and federal regulations on waste segregation, handling and disposal. Legislation requires that biomedical waste be handled, transported and disposed of in such a way as to avoid transmission of potential infections. Waste, such as liquid blood or body fluid drainage in containers that cannot be emptied into a toilet, must be packaged as biomedical waste. Ensure that appropriate personal protective equipment consistent with routine practices is used. (See Section 4.3) Contact the Environmental Health Officer for information or direction regarding waste handling and disposal.

3.10.1 Recommendations for Biomedical Waste Handling

Local municipal regulations on waste segregation must be followed.

Biomedical waste (sharps) containers and transport packaging can be ordered through Environmental Health Services using the order form located on OneHealth.

Segregate and package sharps waste in a labelled, puncture resistant container.

Place biomedical waste in a plastic bag, seal securely and package in a biohazard labelled, leak-proof container which can be disposed of or safely cleaned after emptying.

Store in a location that protects it prior to pick up/disposal.

Dispose of waste frequently.



January 2017 29

When handling waste, wear protective apparel (gloves and gown/apron). It is recommended that anyone routinely handling biomedical waste should be vaccinated against Hepatitis B.

Table 3 Types of Waste Type of Waste Definition Examples

Biomedical Human blood or body fluid waste. Contaminated sharps (materials that can puncture, penetrate or cut the skin and have come in contact with a body fluid or microorganisms)

Human fluids, blood and blood products, items saturated or dripping with blood, body fluids contaminated with blood, needles, lancets, laboratory glass that is broken or easily broken, scalpel blades

NOTE: Biomedical waste does NOT include: waste that is of household origin or general waste from

clients on additional precautions.

General Materials that have not been contaminated or excessively soiled with blood or other potentially infectious materials

Examples include:

soiled dressings

dialysis waste (i.e. tubing, filters, towels and disposable sheets)

IV bags/tubing

Diapers, adult incontinence briefs

soiled feminine hygiene products disposable gloves/aprons

catheters

specimen containers

medication containers Adapted from PIDAC

8

Resources

FNIHB AB Region Resources:

Home Care Procedure Manual

Post-Natal Manual

Vaccine Management Guidelines Government of Alberta

Disposal of Biomedical Waste

http://environment.gov.ab.ca/info/library/8425.pdf



January 2017 30

4.0 Additional Precautions Occasionally, routine practices are not sufficient to interrupt the transmission of certain organisms and additional precautions are required. Additional precautions are required in conjunction with routine practices to protect staff, clients, and visitors/family members from suspected or identified infectious agents. These precautions may include use of PPE, special accommodation, environmental cleaning, etc., and are implemented following a point of care risk assessment.

Additional precautions are based upon the actual mode of transmission of the organism and are classified as: 2,8

Contact Precautions

Droplet Precautions

Airborne Precautions

Additional precautions are implemented differently in various settings: i.e. what is required in a home and community care setting is different from what would be required in a hospital setting or other residential setting where the risk of transmission of infection is higher.

Should a client who requires additional precautions need to seek medical care, the office or site should be notified in advance of the visit of the need for additional precaution requirement. In cases of droplet or airborne precautions the client should be asked to wear a surgical mask and perform hand hygiene prior to leaving their home. Clients should also be instructed to minimize contact with others during transportation to seek medical advice. Clients should not take public transit or utilize volunteer transportation services while they are infectious. Where NIHB transportation services are utilized, it is preferred that the client be transported on their own, or with others who have the need for similar precautions.

In all cases when additional precautions are necessary, clients and family members should receive basic education about how to prevent transmission of the illness and proper use of any personal protective equipment needed. No special treatment is required for linen or dishes and eating utensils for individuals on precautions.

4.1 Contact Precautions Contact precautions are used for clients known or suspected to have microorganisms that can be spread by direct contact with the client or by indirect contact with environmental surfaces or client care equipment.

Examples of conditions that may require contact precautions are:

enteric infections

skin infections (impetigo, scabies, MRSA, non-contained abscesses) and

respiratory infections, especially when respiratory etiquette is not used.



January 2017 31

Contact precautions require that:

gloves are worn for all direct contact with the client as well as direct contact with the client’s immediate environment, personal items and equipment.

a clean gown be worn to protect the health care provider’s clothing from contamination when there is substantial contact with the client or environmental surfaces, as well as when the client is incontinent or has diarrhea, an ileostomy, a colostomy, or uncontained wound drainage. After the gown and gloves are removed, hand hygiene is required.

No special treatment is required for linen, or dishes and eating utensils. Attention should

be focused on preventing the transmission of the organisms to the next client or

environment visited.2

4.2 Droplet Precautions

Droplet precautions are used for clients known or suspected to have microorganisms transmitted by large particle droplets (larger than 5 microns). These droplets may be produced during coughing, sneezing or certain procedures such as suctioning. These particles are propelled a short distance, usually less than two metres (six feet), and do not remain suspended in the air.2

Common conditions that may be encountered in the home and community care setting and that may require this level of precaution include:

acute respiratory infection like rhinovirus, influenza, parainfluenza

streptococcal pharyngitis, and

Mumps and rubella (if HCW is not immune)

Droplet precautions require:

health care providers wear a surgical mask and eye protection when providing direct care to the client or when they are in close proximity (2 metres).

that symptomatic individuals should be spatially separated from others (2 metres), although they do not require placement in a separate room.

No special treatment is required for linen or dishes and eating utensils.2

4.3 Airborne Precautions

Airborne precautions are used for clients known or suspected to have microorganisms spread by the airborne route. These may consist of small particle residue (5 microns or smaller) that result from the evaporation of large droplets or dust particles containing skin squamous and other debris. These can remain suspended in the air for long periods of time and are spread by air currents within a room or over a long distance.2

Conditions that require this level of precautions:

measles (if HCW is not immune)

infectious tuberculosis

varicella (if HCW is not immune)

airborne precautions may also be warranted when involved in aerosol generating medical procedures.



January 2017 32

Airborne precautions require:

health care providers wear an N95 respirator, for which they have been fit tested, upon entering the airspace of clients with known or suspected to have microorganisms spread by the airborne route.

Resources

FNIHB AB Region

Point of Care Risk Assessment

Chain of Infection


Routine Practices and Additional Precautions in Healthcare Settings 2013

5.0 Laboratory Specimens All clinical specimens are considered potentially infectious and therefore must be handled with care and collected and transported appropriately.

5.1 Collecting Specimens Perform Point of Care Risk Assessment (PCRA) and don appropriate PPE

Use specified sterile container or specimen bottle and fill as per instructions

Secure the lid to prevent leakage. Do not send leaking or soiled containers.

If outside of the container is soiled, wipe with disinfectant

Label all specimens and place into plastic pouch, requisition is to remain in the outside pouch of the bag

Remove PPE and perform Hand hygiene

Resources


Laboratory Guidelines - Proper Labelling and Specimen Submission

5.2 Transportation of Specimens For the purpose of transportation, the Transportation of Dangerous Goods Regulation must be followed for all patient specimens that require road or air transport.

All patient specimens are classified as either:

Category A, Infectious Substance

Category B, Biological Substance or

Exempt Human Specimens

Resources

Transportation of Dangerous Goods Manual: Section 3.0; Class 6.2


http://www.provlab.ab.ca/guide-to-services.pdf



January 2017 33

6.0 Food Safety

Foodborne illness can be very serious and even life threatening to individuals, especially preschool children, older adults in health care facilities and those who are immunocompromised. Ensuring effective food safety is essential in the health care and community setting. Health care workers involved in food preparation should complete a recognized Food Sanitation and Hygiene Course from Environmental Health Services FNIHB or Alberta Health Services.

6.1 Food Safety Tips The food handler represents the most important and controllable source of food

contamination. Performing effective hand hygiene is key to breaking the chain of infection. Hand hygiene must be practiced before, during, and after preparing or handling food.

Many foods are inherently contaminated from the source such as beef with E.coli or eggs with salmonella. Safe food handling practices are key when dealing with hazardous foods.

Maintain effective temperature control. Ensure there is proper cold and hot holding to keep cold foods cold and hot foods hot

Minimize the time foods remain in the danger zone during preparation and service. (i.e temperature range between 40C and 600C where microorganisms may grow and multiply)

Cook and reheat foods to required internal temperatures, verifying critical temperatures with a thermometer

Clean fresh vegetables and produce with running water. Rub with hands or scrub with a vegetable brush while rinsing, if skin/rind is firm enough

Prevent cross contamination during food preparation and storage. i.e. ensure juices from raw meats, seafood, poultry or eggs do not mingle with or touch other ready to eat foods in the fridge or in the preparation area like on cutting boards.

Keep dry food stored in food grade containers, properly sealed and labelled to prevent contamination by pests.

Clean and disinfect all food contact surfaces before, during and after preparing food.

Dishware and utensils may serve as a vector for disease transmission if not properly cleaned. Ensure all dishware and utensils are effectively washed and disinfected using either a three compartment sink method of dishwashing or mechanical dishwashing. All dishes shall be air dried. Tea towels are not permitted for drying.

Resources

FNIHB AB Region

Food Safe Course (Connect with Environmental Health Officer)

Food Safety Tips:

Safe Minimum Temperatures for Food

http://www.foodsafety.gov/keep/charts/mintemp.html



January 2017 34

7.0 Pests and Infestations

Occasionally home and community care workers may encounter pests (e.g. bed bugs, mice, cockroaches) in individual residences. Pests such as mice and cockroaches can carry disease and contaminate environmental surfaces through their urine and feces. Hantavirus pulmonary syndrome is an example of a disease that is spread through contact with contaminated urine or feces from deer mice.

Some pests are nuisance pests and are not associated with transmission of disease but health care workers will need to avoid becoming a “vehicle” for their transfer to other houses. Beg bugs are one such example that is commonly found in public places and personal residences. The presence of bed bugs in these environments does not prohibit the delivery of health services but provisions must be taken to prevent spread to other homes or facilities. HCW may also encounter infestations of lice (pediculosis) and mites (scabies) when

providing client care. These pests are ecotoparasites that live off of human hosts but

are not associated with disease transmission. However, they can be passed from

person to person and therefore the HCW must take care not to pass to another client or

work site. Infection control practices for the HCW may include:

Good hand hygiene

Contact precautions (gown and/or gloves) for direct client care

Resources

FNIHB AB Region

Appendix 8: Providing Care in Bed Bug Infested Residences

Environmental Public Health Services: “Hantavirus: What You Need to Know to Prevent Hantavirus Pulmonary Syndrome (HPS).

Organism specific:

Scabies

BC Centre for Disease Control, Scabies

My Health Alberta, Scabies

CPS: Scabies Position Statement

Caring for Kids, CPS

Lice

My Health Alberta ca, Lice

Bedbugs

Health Canada, Bed Bugs

PICNET Infection Control Guidelines, Appendix 6.

Rodents

Health Canada

Rats and Mice

Hantavirus

Pest Control Tips

http://www.bccdc.ca/resource-gallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/CD%20Manual/Chapter%203%20-%20IC/InfectionControl_GF_Scabies_Feb_2005.pdf

https://myhealth.alberta.ca/health/Pages/conditions.aspx?hwid=hw171811

http://www.cps.ca/en/documents/position/scabies

http://www.caringforkids.cps.ca/handouts/scabies

https://myhealth.alberta.ca/health/pages/conditions.aspx?Hwid=hw51114

http://www.healthycanadians.gc.ca/product-safety-securite-produits/pest-control-products-produits-antiparasitaires/pesticides/tips-conseils/bedbugs-punaises-lits-eng.php

http://www.bccdc.ca/resource-gallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/Other/Epid_GF_PicNet_Home_Community_Care_August_2009.pdf

http://healthycanadians.gc.ca/product-safety-securite-produits/pest-control-products-produits-antiparasitaires/pesticides/tips-conseils/rats-eng.php?_ga=1.76841367.322793662.1430860465

http://healthycanadians.gc.ca/diseases-conditions-maladies-affections/disease-maladie/hantavirus/index-eng.php

http://www.healthycanadians.gc.ca/product-safety-securite-produits/pest-control-products-produits-antiparasitaires/pesticides/tips-conseils/index-eng.php#a2



January 2017 35

8.0 Healthy Workplace Strategies/Occupational Health

Protecting the health of the HCW is essential in all health care settings, including the home and other community care sites. The HCW’s own practices, both personal and professional, should be a role model for the client, family, and other members of the community at large. Health workplace strategies include:8

Immunization

TB Screening for HCW

Post Exposure Protocol

Respiratory Protection Program


Education and Training

8.1 Immunization The promotion and provision of immunizations to HCW is essential in preventing spread of vaccine preventable diseases. Minimum immunization requirements are based on a risk assessment conducted by the employer for exposure to vaccine preventable diseases related to the work environment.

The employer may develop internal policies requiring immunizations as a condition of employment and should offer appropriate immunizations. There should be a method for documentation of immunization status in HCW.7,8

At start of employment, the health care worker should have their immunization history assessed and a record of immunization on file in their confidential employee health record. They also should maintain their immunizations as per the Alberta routine immunization program throughout their employment. Recognition and awareness of the HCW’s immune status helps define the susceptibility of the provider in the event of exposure to a communicable disease. The health history also helps identify any work limitations or risk factors for the provider or client.

Resources

FNIHB AB Region

Vaccine Program Summary Sheets Alberta Health

Alberta Immunization Policy


Canadian Immunization Guide o HCW Immunization Recommendations

http://www.health.alberta.ca/documents/AIP-General-Guidelines.pdf

http://www.phac-aspc.gc.ca/publicat/cig-gci/p03-work-travail-eng.php#table-1



January 2017 36

8.2 TB screening for Health Care Workers FNIHB AB Region Tuberculosis program focuses on early detection and treatment, prevention and reduction of transmission in First Nations communities in Alberta. Screening is a comprehensive component of the program which includes screening for Health Professionals.

Baseline screening for single step tuberculin skin testing is recommended for healthcare workers at risk for potential occupational exposure to infectious TB. Two step testing may be required for those that work at high risk settings as based on the Care Algorithm.

Resources

FNIHB AB Region

Vaccine Program Summary – Tuberculin

Tuberculosis section of CDC Manual on OneHealth: includes resources for staff and clients


Care Algorithm: TB Screening in Health Care Workers (accessed through OneHealth)

8.3 Blood and Body Fluid Post Exposure Protocol Effective management of staff exposures to blood or body fluids is essential. Health Care Workers who may be exposed to blood and body fluids (i.e. recipients) are at increased risk of contracting Hepatitis B, C, and/or HIV. A timely assessment is required should an exposure occur.

The FNIHB Alberta Region “Management of Blood and Body Fluid Exposure Protocol” is available to all community health care staff, and is summarized below:

If a HCW is potentially exposed to blood and body fluid (cerebral spinal fluid, semen, vaginal fluid) via contact of the mucous membranes, non-intact skin or subcutaneous tissue:

1. Administer immediate first aid 2. Call health protection 24 hour number (780) 218-9929 for assessment

and follow-up Information that will be assessed includes: details of incident and

source, HBV immunization history and anti-HBs information for recipient

Resources

FNIHB AB Region:

Poster: “Needlestick & Blood/Body Fluid Exposure Protocol”



January 2017 37

8.4 Respiratory Protection Program Staff who may potentially be required to wear N95 masks must comply with the regional respiratory protection protocol.

Resources

FNIHB AB Region:

Respiratory Protection Program, Policy Statement


8.5 Education and Training Keeping current and up to date on infection prevention and control is essential for all health care workers. Participation in education and training sessions should be documented by their supervisor/manager. Staff should be familiar with infection prevention and control policies and they relate to the work environment.

The HCW should provide education for the client and family as appropriate for the presenting condition. Education should include information on:

hand hygiene: before leaving their residences for public areas and upon returning home from outings; after using the toilet; and before eating or preparing food.

respiratory etiquette: staying home if sick, covering cough, hand hygiene, and keeping proper separation from others.

chain of infection: including minimizing mucous membrane exposure (hand contact with eyes, mouth and nose).

environmental cleaning and

use of personal care items such as foot care products, toothbrushes, etc.,

Resources:

FNIHB AB Region:

Introduction to Infection Prevention and Control and resources: annual videoconference, OneHealth

Seasonal Influenza Inservice and resources: annual videoconference; seasonal influenza program resources posted to OneHealth

AB Region Nursing Education Department: o Workplace Hazardous Materials Information Systems (WHMIS) o Transportation of Dangerous Goods (TDG)

Alberta Health Services:

Respiratory Hygiene CDC Atlanta

Cover Your Cough


http://www.cdc.gov/flu/protect/covercough.htm



January 2017 38

9.0 Outbreak Management

An outbreak is defined as the occurrence of more cases of disease than expected in a

given area or among a specific group of people, over a particular period of time.

Early identification and prompt reporting of suspected outbreaks is very important as it

can allow for early implementation of control measures that interrupt transmission,

reducing the spread of illness and the number of people affected. If you suspect an

outbreak, contact the Regional CDC Nurse Manager at 780-495-5439.

Resources

FNIHB AB Resources

Outbreak Management.



January 2017 39

Definitions

Aseptic Technique: Practices based upon the principle that infection may be introduced into the body from the outside. These practices prevent the introduction of microorganisms into the body and maximize and maintain asepsis (absence of pathogenic organisms).

Additional Precautions: These precautions (i.e. contact precautions, droplet

precautions, and airborne precautions) are carried out in addition to routine practices

when infections caused by organisms transmitted by these routes are suspected or

diagnosed. They include the physical separation of infected or colonized

clients/residents from other individuals and the use of barriers (i.e. gowns, gloves,

masks) to prevent, or limit, the transmission of the infectious agent from colonized or

infected individuals to those who are susceptible to infection or to those who may

spread the agent to others.

Alcohol-based Hand Rub (ABHR): A waterless hand antiseptic that can be used for

performing hand hygiene if hands are not visibly soiled. The optimal strength of alcohol-

based hand rubs is 60% to 90% alcohol.

Antibiotic Resistant Organism (ARO): A microorganism that has developed

resistance to the action of several antimicrobial agents and that is of special clinical or

epidemiological significance.

Cleaning: The physical removal of foreign material (i.e. dust, soil, organic material such as blood, secretions, excretions and microorganisms). Cleaning physically removes rather than kills microorganisms. It is accomplished with water, detergents and mechanical action. Thorough and meticulous cleaning is required before any equipment/device may be decontaminated, disinfected and/or sterilized.

Colonization: The presence and multiplication in or on the body of microorganisms without any symptoms of infection or detected immune reaction. Colonization is often a natural process in the development of naturally occurring “normal flora”.

Community Associated Infection: An infection that is acquired before admission to hospital or is incubating at the time of admission.

Community Health Nurse: A nurse who collaborates in the delivery of comprehensive Health Programs which include promoting, protecting and preserving the health of First Nations populations on reserve. Can include Public Health Nurse and the Home Care Nurse.

Direct Care: Providing hands-on care, such as bathing, washing, turning client/resident,

changing clothes/diapers, dressing changes, care of open wounds/lesions or toileting.

Feeding and pushing a wheelchair are not classified as direct care.

Environmental Health Officer (EHO): EHOs work in an inter-professional and cross-sectorial manner to ensure that clients are protected from environmental public health risks such as infectious diseases, chemical contaminants, and physical hazards.



January 2017 40

Health Care Associated Infection: An infection acquired during the course of receiving any type of treatment for other conditions, or that a Health Care Worker acquires while performing their duties within a health care setting.

Hand Hygiene: A process for the removal of soil and transient microorganisms from the hands. Hand hygiene may be accomplished using soap and running water or by the use of alcohol-based hand rubs. Optimal strength of alcohol-based hand rubs should be 60% to 90% alcohol.

Health Care Provider/Worker: Individual providing or supporting health care services that will bring them into contact with clients. This includes, but is not limited to: nurses, community health representatives, health care aids, dental therapists, support services (e.g. housekeeping, dietary, maintenance, hairdressers), allied health care professionals, and external health care providers.

Home and Community Care: A wide-range of medical, nursing, rehabilitation, hospice, and social services delivered to clients in their place of residence (i.e. private residence, senior living centre, assisted living facility). Home health care services include care provided by home health aides and skilled nurses, respiratory therapists, dieticians, physicians, chaplains, and volunteers; provision of durable medical equipment; home infusion therapy; and physical, speech and occupational therapy.

Home Care Nurse: A nurse whose focus is clinical care and treatment that is directed towards health restoration, health maintenance and palliation in order to enable the client to live in their home.

Hospital-grade Disinfectant: A disinfectant that has a drug identification number (DIN)

from Health Canada indicating its approval for use in Canadian hospitals.

Infection: An invasion of the body by microorganisms that multiply and cause an interaction between the host and the organism. The interaction may only be a detectable immune response such as a TB skin test conversion (subclinical infection) or produce signs and symptoms resulting from the altered physiology and/or associated cell damage (clinical disease).

Infection Prevention and Control: Evidence-based practices and procedures that,

when applied consistently in health care settings, can prevent or reduce the risk of

transmission of microorganisms to and between health care workers,

clients/patients/residents and visitors.

Loaned Equipment: Medical equipment that is borrowed, shared or consigned to be used for clients. Reprocessing is carried out at both loaning and receiving sites.

Medical Officer of Health (MOH): A medical practitioner with training, knowledge, skills and experience in community medicine who is designated by the Minister of Health under the Public Health Act. The MOH provides advice and direction on public health issues including health promotion and health protection and related practices, bylaws and policies. The MOH has jurisdiction for public health issues and reports to the public those matters which are deemed to be in the public interest.



January 2017 41

Nosocomial Infection: An infection that develops during hospitalization or after discharge as a direct result of hospitalization.

Personal Protective Equipment (PPE): Clothing or equipment worn by staff for protection against hazards such as blood, body fluids, and infectious secretions.

Routine Practices: Routine practices is the term used by Health Canada/Public Health Agency of Canada to describe the system of infection prevention and control practices recommended in Canada to be used with all clients/patients/residents during all care to prevent and control transmission of microorganisms in all health care settings.



January 2017 42

Appendices

1A: Hand Hygiene: Alcohol Based Hand Rub

1B: Hand Hygiene: Hand Washing

1C: 5 Moments of Hand Hygiene

2A: Donning PPE

2B: Doffing PPE

3A: Glove Use

3B: Mask Use

4: Admission Risk Assessment

5: Transportation of Dangerous Goods, Fact Sheet for Road Transport

6: Environmental Cleaning

7: FNIHB Alberta Region: Single Use Policy, January 14, 2014

8: Providing Care in Bed Bug Infested Residence

References



January 2017 43

Appendix 1A: Hand Hygiene- Alcohol Based Hand Rub

To be effective alcohol based hand rubs (ABHR):

Shall contain one of the following: ethanol (ethyl), isopropanol (iso-) and n-propanol

Contain a minimum Alcohol concentration of 60%.

• ABHR have been proven effective at 60-90% alcohol content

Must be provided at the point of care where HCW can clean their hands without

leaving the client

Must be accepted by the HCW to encourage use.

• Consistency, dry times, residual build up may affect product acceptance and use.

Must be rubbed thoroughly into all surfaces of the hands and allowed to air dry

Must be washed off hands with soap and water when there is a residual build-up

Are flammable and bulk products must be stored according to fire code regulations

Have the potential for misuse or illegal ingestion and therefore choice of product and

placement of dispenser is important



January 2017 44



January 2017 45

Appendix 1B: Hand Hygiene- Hand Washing When hands are visibly soiled or where hand washing is indicated by PCRA, hand wash with soap and water:

A neutral soap from a disposable dispenser should be used for hand washing. o The routine use of antimicrobial soaps for hand hygiene is not necessary.

However, antimicrobial soap with residual antimicrobial activity should be used for aseptic procedures.

Remove jewelry prior to washing. Fingernails should be kept short. Artificial nails and nail extenders are not acceptable in health care settings, as they are known to harbour infectious organisms

Wash all surfaces of the hands, in between fingers, knuckles and wrists for at least 15 seconds

Use single-use disposable paper hand towels to dry hands, not multi-use hand towels for drying



January 2017 46



January 2017 47

Appendix 1C: 5 Moments of Hand Hygiene



January 2017 48



January 2017 49

Appendix 2A: Donning PPE



January 2017 50

Appendix 2B: Doffing PPE



January 2017 51

Appendix 3A: Glove Use The choice of glove should always be made according to the task that is being done and only worn for that task. Hand hygiene is performed before and after any glove use.

Medical Gloves

Type Use Advantages Disadvantages

Vinyl Protection for: o Minimal exposure to blood/body

fluids/infectious agents o Contact with strong acids and

bases, salts, alcohols

Protection for staff with documented skin breakdown

Good level of protection but based on the quality of the manufacturer

Medium chemical resistance

Not recommended for contact with solvents, aldehydes, ketones

Quality varies with manufacturers

Punctures easily when stressed

Rigid – not elastic

Latex Activities that require sterility

Protection for: o Heavy exposure to blood/body

fluids/infectious agents o Contact with weak acids and

bases, alcohols

Good barrier qualities

Strong and durable

Has re-seal qualities

Good comfort and fit

Good protection from most caustics and detergents

Not recommended for contact with oils, greases and organics

Not recommended for individuals in the vicinity of those who have allergic reactions or sensitivity to latex

Nitrile Protection for: o Heavy exposure to blood/body

fluids/infectious agents o Tasks of longer duration o Tasks with high stress on

glove o Tasks requiring additional

dexterity o Chemicals and

chemotherapeutic agents o Recommended for contact

with oils, greases, acids, bases

o Sensitivity to vinyl

Preferred replacement for vinyl gloves when a documented allergy or sensitivity occurs

Offers good dexterity

Strong and durable

Puncture resistant


Excellent resistance to chemicals

Not recommended for contact with solvents, ketones, esters

Neoprene Replacement sterile gloves for latex when a documented allergy or sensitivity occurs

Recommended for contact with acids, bases, alcohols, fats, oils, phenol, glycol ethers

Good barrier qualities

Strong and durable


Good protection from caustics

Not recommended for contact with solvents

Source: PIDAC: Routine Practices and Additional Precautions in All Health Care Settings, November 2012. Appendix M: Advantages and Disadvantages of PPE

9



January 2017 52

Glove Use:

APPROPRIATE USE OF GLOVES

1. Wear gloves for contact with mucous membranes, non-intact skin including undiagnosed

rashes, blood, body fluids, secretions, excretions or equipment and environmental surfaces contaminated with any of these.

2. Perform hand hygiene before putting on gloves.

3. Remove gloves and discard immediately after the activity for which they were used. Do not re-use or wash gloves.

4. Change gloves between care for each patient.

5. Perform hand hygiene after gloves are removed due to possible contamination of hands during glove removal.

Figure 10: Putting on gloves Figure 11: Taking off gloves

Adapted from PIDAC 5



January 2017 53

Appendix 3B: Mask Use

Principles for using masks and respirators:

perform hand hygiene before putting on a face mask

the mask should fit snugly over the face and should fully cover the nose, mouth and chin

the metallic wire part of the face mask should be fixed securely over the bridge of the nose to prevent leakage, if using a N95 respirator, use three finger method to fix the nose clip over the bridge of the nose, being careful to avoid crimping in order to prevent a gap

tie all strings that keep the mask in place or fix the ear loops of the mask around the ears properly. Do not dangle the mask around your neck

if using N95 respirator, a seal check should be conducted each time the respirator is donned.

change mask if it becomes wet, soiled or dirty

perform hand hygiene after removing and discarding the mask



January 2017 54

APPROPRIATE USE OF SURGICAL MASKS

Put on mask immediately before the activity for which it is indicated.

Secure mask over the nose and mouth.

Remove mask immediately after the activity for which it is used.

Change mask if it becomes wet.

Do not touch mask while being worn.

Do not allow mask to hang around the neck.

Do not fold mask or store in a pocket.

Do not re-use mask.

Perform hand hygiene after removing mask

Figure 14: Putting on mask

Figure 15: Taking off mask

APPROPRIATE USE OF RESPIRATORS

Put on respirator immediately before the activity for which it is indicated.

Remove respirator as soon as it is safe to do so.

Use only a fit-tested respirator.

Perform a seal-check each time a respirator is applied.

Change respirator if it becomes wet or soiled.

Remove respirator correctly and discard immediately after use.

Perform hand hygiene after removing the respirator.

Figure 16: Putting on respirator Figure 17: Taking off respirator

Adapted PIDAC5



January 2017 55

Appendix 4: Admission Risk Assessment The admission risk assessment of the client should include, but not be limited to:

tuberculosis: previous or present evidence (if the client is from an identified risk group)

antibiotic-resistant organisms such as Methicillin Resistant Staphylococcus aureus (MRSA), Vancomycin Resistant Enterococci (VRE)

the presence of any chronic infections

skin and soft-tissue infections (boils, cellulitis), determine if secretions are contained

infestations (i.e. scabies, head or body lice)

gastrointestinal illness (nausea, vomiting, diarrhea)

any acute respiratory infection (fever, cough)

the client’s ability to comply and cooperate

continence issues Ongoing assessment of the client should include:

skin and soft-tissue infections (boils, cellulitis), determine if secretions are contained

infestations, if previously identified (i.e. scabies, head or body lice)

gastrointestinal illness (nausea, vomiting, diarrhea)

any acute infection (fever, cough)

the client’s ability to comply and cooperate

continence issues

concerns identified during initial assessment Factors demonstrated to increase one’s risk of developing infections include7:

extremes of age

recent or extended stay in an acute care facility, or recurrent hospitalizations

invasive procedures and presence of invasive devices (i.e. IV, urinary catheter, tracheostomy, gastrostomy feeding tube)

recurrent antibiotic use

presence of a surgical wound, decubitus ulcer, or other chronic wound

exposure to a person who is infected with an organism and had draining skin lesions or wounds or copious respiratory secretions

age or medication-related malnutrition and/or immunosuppression

chronic illness and/or underlying medical conditions (e.g. HIV/AIDS)

conditions requiring extensive hands-on care

poor personal and/or household hygiene

cognitive challenges (i.e. brain injury, dementia, mental health conditions) NOTE: The presence of a microorganism such as MRSA or VRE should not exclude the client from home or community care as long as they meet the criteria for home nursing services

18.



January 2017 56

Appendix 5: Transportation of Dangerous Goods, Fact Sheet for Road Transport of Sharps as A Carrier

Sharps Road Transport

When a health professional must transport sharps (i.e. needles, syringes and other sharps) from one location to another for use in service delivery which is not the final disposal, the individual is acting as a carrier.

Used sharps are considered Dangerous Goods Class 6.2 (Infectious Substances) for transporting between facilities. As such, transportation of dangerous goods regulation requires the following:48

Sharps contaminated with blood or body fluids, including needles are considered infectious and must be handled as such.

Sharps must be contained in a leak proof, rigid, puncture resistant primary container; i.e. sharps container.

The container is then placed in a rigid outer container such as a hard plastic cooler. Soft side coolers or nursing bags are not considered appropriate outer packaging.

If the sharps container contains liquid, an absorbent should be placed between the primary and outer container to ensure no leakage will occur during transport.

Labelling and Documentation

When carrying used sharps, the outer package must be labelled with a Class 6 label (Infectious Substance).

The class 6 label is only used when transporting USED sharps, otherwise, the label on the outer package must be covered or removed. Simple solutions may include utilizing a double sided label with one side indicating EMPTY and the other side Class 6. It may be fastened to the rigid outer

package with double side tape or Velcro.

As a carrier an inventory list is required and is to be placed within the cooler

Example inventory list:

Date: January 23, 2014

Transported by: (name) Sally Smith

Item Number of containers Class

Sharps Container with dental sharps

1 6.2 infectious Substance

The inventory list shall be retained in records for 2 years.

Carriers must have a valid TDG certificate and carry it on your person when transporting dangerous goods including used sharps.

Securing and transporting

Ensure all items are properly stowed and secured. Rigid outer packs must have securely fitted lids and be able to withstand transport

conditions. Resources:

Public Health Agency of Canada, Laboratory Safety Office, 2014. Transportation of Dangerous Goods, Online Nursing Manual



January 2017 57

Appendix 6: Environmental Cleaning

Environmental cleaning is one of the most important steps in breaking the chain of infection. Environmental cleaning consists of :

Routine cleaning followed by disinfection of health facility using hospital grade disinfectants

Additional cleaning and disinfection of high touch surfaces, medical equipment and devices or in outbreak situations

Education for janitorial staff

Auditing and review of cleaning practices

Disinfectants

Hospital grade disinfectants must be registered with a Drug Identification Number (DIN) and must be used in accordance to manufacturer’s instructions. Products such as vinegar, baking soda, tea tree oil are not considered hospital grade disinfectants, have no registered DIN and cannot be used in the health care setting for disinfection purposes. Manufacturer’s instructions must be followed for use to ensure adequate concentration and contact time is achieved.



January 2017 58

Selecting a Disinfectant

When choosing a disinfectant consideration should be given to:

Broad antimicrobial spectrum: review the product specifications and microbiological testing data

Stability: Review shelf life information for concentrate and in-use dilution

Toxicity: Review material safety data sheets for health hazards associated with product use

Odour (absent or mild): To reduce possible sensitivity, allergic or asthmatic reactions

Cost-Review: cost of pre-diluted, ready-to-use product versus concentrate

Water Solubility: important if concentrate is under consideration

Cleaning ability: Evaluate for surfactants or other cleaners that are important for mechanical removal of soil and organic material

Rinsing: If rinsing is needed, the entire cleaning procedure will take longer

Contact time: check product monographs - usually less than or equal to 10 minutes

Not all disinfectants are appropriate for all surfaces or applications. Choosing the best disinfectant to satisfy the specific needs of the facility or environment is essential. Often one disinfectant may not be appropriate for all applications, therefore staff education and training is essential Hospital grade disinfectants must be registered with a Drug Identification Number ( DIN) and must be used in accordance to manufacturer’s instructions. Products such as vinegar, baking soda, tea tree oil are not considered hospital grade disinfectants, have no registered DIN and cannot be used in the health care setting for disinfection purposes.

Disinfectants may include:

Accelerated Hydrogen peroxide

Alcohols (60-90% ethyl or isopropyl alcohol)

Chorines; sodium hypochlorite or calcium hypochlorite (bleach)

Iodophors

Phenolics (not to be used on toys or in daycares)

Quaternary Ammonium compounds Disinfectant wipes (hospital grade) may be used at point of care for disinfecting patient care surfaces and equipment but should not be used as a primary disinfectant product for routine cleaning.



January 2017 59

Preparing Household Bleach As a Disinfectant

Hypochlorite (bleach) is an effective low and intermediate level disinfectant, depending

on the concentration of solution prepared and contact time. Most environmental

surfaces can be disinfected with a low level disinfectant with recommendations for

concentrations to a 1000 ppm.12 Environmental cleaning with bleach solutions greater

than 1000 ppm are during an outbreak or for blood and body fluid clean up. Solutions at

these higher concentrations can also be used for disinfection of semi-critical medical

equipment.

Table 4: Dilution of Household Bleach to Achieve Desired Chlorine Levels

Dilution* Preparation

Level of Available Chlorine

Contact Time for Inactivation of C.Difficile Spores % Chlorine # ppm

1:100 1 part bleach + 99 parts water

0.05% 500 ppm


0.1% 1000 ppm 30 minutes


0.5% 5000 ppm 10 minutes

*Dilution of household bleach containing 5% sodium hypochlorite with 50,000 parts per million (ppm) available chlorine. Adapted from PIDAC PIDAC: Best Practices for Environmental Cleaning for Prevention and Control of Infections | May, 2012

12

Bleach solution must be made fresh daily to preserve effectiveness. Standard

household bleach solution ranges from 5% to 6% sodium hypochlorite solution

(50,000 ppm available chlorine).If using chlorine bleach as a disinfectant for

environmental surfaces or on some non-critical items, the following dilution tool is

helpful for determining ratios of chlorine to water:

Public Health Ontario Chlorine Dilution Calculator.

For example: Preparing a one litre low level disinfectant solution of 500 ppm with 5.25

% bleach.

The dilution ratio of bleach to water is 1:100. You would need 10 mL of bleach to

990 mL of water.

http://www.publichealthontario.ca/en/ServicesAndTools/Tools/Pages/Dilution-Calculator.aspx



January 2017 60

Cleaning Basics

1. Work from highest part of room to lowest part of room, start by cleaning lights,

ceilings and then working towards floor

2. Work from Outside to Inside: Clean all wall attached object first before horizontal surfaces like counters and sinks, then finish with client contact areas

3. Work from cleanest surfaces of rooms to dirtiest. For example when cleaning the bathroom start with mirrors or lights, work to sink and tub and then to toilets and floor.



January 2017 61

Tips for Effective Cleaning

Remove gross soil prior to cleaning

Dry mop before damp mop

Do not double dip cloths

Change cloths and mop heads frequently

Change cleaning solutions as recommended by manufacturer’s instructions, when

visibly soiled

And after a blood and body fluid spill cleanup

Be alert for needles and sharp instruments

Never top up dispensers when refilling is required. Clean dispenser first and then

refill

Perform hand hygiene

Avoid spraying of cleaning solutions onto a surface to reduce exposure to

aerosolized chemicals, spray directly on cleaning cloth instead

Equipment used for cleaning must be cleaned, disinfected and dried after use, or

disposed of if single use.

Cleaning carts/waste disposal carts should be cleaned daily.

Storage and Use of Cleaning Supplies:

All chemicals used for cleaning must be;

Appropriately labelled and stored as per manufacturer’s instructions

MSDS sheets must be maintained up to date and accessible

Staff must be trained and current in WHMIS ( workplace hazardous materials information systems)

If dilution is required, follow manufacturer’s instructions for mixing and verify end concentration is achieved. Never top up bottles

If dispensing chemicals into secondary containers, all containers must be appropriately labelled, and concentration must be monitored as the chemical may loose its effectivity over time

Janitorial staff should be made aware of basic infection prevention and controls practices and ensure that appropriate PPE is worn for the cleaning task.

Cleaning chemicals should be maintained secured and not accessible to general staff and clients



January 2017 62

Cleaning Frequency

The frequency of cleaning depends on the type of activity occurring in the room, if the

surfaces are high touch, the vulnerability of the clients, if there are out conditions such

as outbreak in the facility, amount of contamination on the surface.

The following is a guideline for minimum environmental cleaning schedule for a

community/ambulatory care centre:

RECEPTION AREAS, GENERAL OFFICE AREAS, MEETING ROOMS AND HALLWAYS

Daily

Spot clean desks, walls and doors with neutral cleaner

Dust mop, sweep and/or vacuum and damp mop all hard-surface floor areas with neutral cleaner

Vacuum* all carpeted areas and walk-off mats

Empty waste receptacles and dispose of items marked for garbage removal; liners should be changed at least weekly, or more often if odorous; transport waste to designated location; transport recyclables to designated location

Damp wipe reception and waiting area countertops and chairs using a low-level disinfectant solution

Spot clean windows, mirrors and other reflective surfaces

Damp wipe light switches, telephones, doorknobs and handles with a low-level disinfectant solution

Weekly

Damp wipe all fixtures and office furniture using a low-level disinfectant, including: desks, countertops and computers (not screen or keyboard)

Monthly

Clean desk policy: on the last cleaning day of each month tops of all desks, credenzas, file cabinets, etc., to be damp wiped using a low-level disinfectant solution. Staff responsible for clearing horizontal surfaces.

Vacuum* fabric furniture, damp wipe plastic and leather furniture with low-level disinfectant.

Vacuum* around all furniture and baseboards

Dry dust all blinds and damp wipe window ledges

Dry dust all light fixtures, ceiling vents, and areas above 2 metres (6 feet) such as corners and horizontal surfaces

*Note: vacuum should have a Hepa Filter if possible.



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MEDICAL EXAMINATION, LABORATORY AND TREATMENT ROOMS

Daily for every day used

Damp wipe all counters, sinks, dispenser surfaces, cabinet doors and fixtures using a low-level disinfectant solution

Damp wipe all examination beds and tables using a low-level disinfectant solution, including top, undersides and supports), recliners and bedside tables

Empty waste receptacles and wash using a low-level disinfectant solution; liners should be changed; transport waste to designated location; transport recyclables to designated location

Damp wipe all equipment arms and bases using a low-level disinfectant solution, including exam room computer sides/tops, but not screen or keyboard

Damp mop all floors using a low-level disinfectant solution

Vacuum* all carpeted areas

Weekly

Wipe down all walls using a neutral cleaner

Monthly


Dry dust all light fixtures, ceiling vents, and areas above 2 meters (6 feet) such as corners and horizontal surfaces

BATHROOMS

Daily for every day open

Restock all dispensers (paper product, soap, sanitizer, etc.)

Damp wipe all dispensers and surrounding wall areas using a low-level disinfectant solution

Polish mirrors, glass and other reflective surfaces

Disinfect all toilets, toilet seats and handles inside and out, including urinals

Disinfect sinks, faucets and door locks/handles, including showers, tubs, and their plumbing and fixtures, if applicable

Remove liners and empty waste receptacles, including sanitary containers, and wash using a low-level disinfectant solution as required

Spot clean walls as required

Dust mop, sweep and/or vacuum and damp mop all floor areas using a low-level disinfectant solution

Monthly

Damp wipe walls up to 2 metres (6 feet) using a neutral cleaner


Dry dust all light fixtures, ceiling vents, and areas above 2 metres (6 feet) such as corners and horizontal surfaces



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COFFEE AREAS AND LUNCH ROOMS

Daily for every day that staff are working

Damp wipe counter tops, chairs, and table tops as required with neutral cleaner

Damp wipe exterior of all appliances and cupboards with neutral cleaner

Empty waste receptacles and dispose of items marked for garbage removal

Clean sinks, faucets and handles with a low-level disinfectant

Dust mop, sweep and/or vacuum and damp mop hard-surfaces floor areas with neutral cleaner

Weekly

Clean drinking fountains or water dispensers with non-phenolic disinfectant

Monthly

Detail edge vacuum around all furniture and baseboards

Damp dust all blinds and damp wipe window ledges

Damp dust all light fixtures, ceiling vents, and areas above 2 metres (6 feet) such as corners and horizontal surfaces

STAIRWELLS

Clean handrails, ledges, stairs, risers, landings, etc.; professionally scrub, water extract

ANNUALLY FOR ALL AREAS

Clean walls and doors to full height, windows, ducts, grills, vents and radiators with appropriate cleaning solution, including any other vertical surfaces and high ceilings

ADDITIONAL SPECIFICATIONS

Surfaces should be cleaned using a low-level disinfectant. Accelerated hydrogen peroxide and quaternary ammonium compounds are appropriate for use in daily cleaning and disinfection of surfaces. Phenolics are also suitable unless this surface could come in contact with an infant or small child (e.g. toys, weight scale, change table). Disinfectant strength should correspond to instructions on the bottle.

Blood and body fluid spills should be cleaned using a detergent to remove organic material. The area should then be disinfected with a disinfectant solution (i.e. one part of household bleach [5.25%] added to nine parts of water applied for at least 60 seconds or any other hospital approved disinfectant). Gloves should be worn during cleanup of any blood or body fluid.

HEPA-filter vacuum cleaners are preferred for all vacuuming.

Double-bucket method (one bucket is disinfectant and the other is clean water) should be used for all mopping.

Cleaning solutions, cloths, mops and tools should be changed frequently, and cleaned and dried between uses.

Frequent-touch areas should receive special attention: at least daily if not more often. (i.e. light switches and doorknobs)



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Clean-up Procedure for Blood and Body Fluids

Spills of blood and body fluid such as urine, feces, vomit must be contained and

cleaned and disinfected immediately. Staff must be familiar with procedure for clean-up

and respond in a timely manner. Appropriate PPE and proper waste disposal are

essential.

Assemble materials required for dealing with the spill prior to putting on PPE.

Inspect the area around the spill thoroughly for splatters or splashes.

Restrict activity around the spill until the area has been cleaned.

Put on gloves; if there is a possibility of splashing, wear a gown and facial protection (mask and eye protection or face shield).

Confine and contain the spill; wipe up any blood or body fluid spills immediately using either disposable towels or a product designed for this purpose. Dispose of materials by placing them into regular waste receptacle, unless the soiled materials are so wet that blood can be squeezed out of them, in which case they must be segregated into the biomedical waste container (i.e., yellow bag).

Disinfect the entire spill area with a hospital-grade disinfectant and allow it to stand for the amount of time recommended by the manufacturer.

Wipe up the area again using disposable towels and discard into regular waste.

Care must be taken to avoid splashing or generating aerosols during the clean up.

Remove PPE as per doffing sequence and perform hand hygiene.

Resources

FNIHB: Environmental Services Training Guide

PIDAC: Best Practices for Environmental Cleaning for Prevention and Control of

Infections in All Health Care Settings, 2nd Edition, May 2012



January 2017 66

Hydrotherapy Tubs 1

Good personal hygiene should be encouraged for all clients. Clients at home or in a group living arrangement may not have access to private bathroom facilities; bath tubs should therefore be cleaned before and after each use.

When selecting a hydrotherapy tub2 for healthcare settings: Tubs purchased for use in healthcare facilities must be non-jetted. This includes air and

water jets. Do not purchase tubs with jets or whirlpools.

Tub surfaces should be constructed of a smooth, non-porous material to facilitate frequent, vigorous cleaning and disinfection. Non-slip surfaces must allow for effective cleaning and disinfection.

Tubs with personal care product dispensing systems should use replaceable bottles for the products instead of reservoirs.

Detailed cleaning, disinfection procedures and preventative maintenance information must be provided in writing by the manufacturer. Manufacturer’s recommended disinfection products must have a DIN from Health Canada and be approved for use.

Cleaning, Low level Disinfection and Maintenance of Patient Care Tubs

There must be a written procedure for daily cleaning and low level disinfection of tubs that follows the manufacturer’s instructions. Responsibility for daily cleaning and disinfection must be identified in the procedure.

Daily cleaning of tubs must be documented. Instructions should be posted and/or readily available to staff.

There must be a written procedure for cleaning and low level disinfection of tubs and lifting devices between patients that follows the manufacturer’s instructions. Responsibility for cleaning and disinfection between patients must be identified in the procedure. The procedure should be posted and the information readily available to staff.

There must be a written procedure for routine and preventative maintenance of tubs that follows the manufacturer’s instructions. Responsible person(s)/departments for preventative maintenance must be identified in the procedure. Maintenance of tubs must be documented, the procedure should be followed and the information readily available for maintenance staff.

Multi-patient use product bottles in tub dispensing systems (e.g. body soap, hair shampoo and/or other personal care products) should be disposable and discarded when empty; not refilled or topped up o If the tub has a reusable reservoir for dispensing personal care products, the reservoir

must be cleaned and dried before refilling. Do not top up.

Clients infected or colonized with an antibiotic resistant organism (ARO) or who have diarrhea or fecal incontinence, with resulting extensive fecal contamination of skin, can be bathed in the bathtub as necessary for healthy skin care regardless of diagnosis. Special considerations:

Bathe colonized or infected client at end of the day wherever possible o Antimicrobial soaps are not require for routine bathing

After use, thoroughly clean the bathtub or shower stall with a hospital approved disinfectant, according to the manufacturer’s instructions.

1 Alberta Health Services: Selection, Cleaning, Disinfection and Maintenance of Patient Care Tubs 2 Jetted Hydrotherapy tubs are no longer permitted in health care facilities due to the high biofilm burden

in the water lines and inability to effectively disinfect jetted tub surfaces

http://www.albertahealthservices.ca/assets/infofor/hp/if-hp-ipc-guidelines-patient-care-tubs.pdf



January 2017 67

Hydrotherapy (Jetted)Tubs Cleaning Protocol

Although best practice standards no longer allows for facilities to be built with jetted

hydrotherapy tubs, there are still some tubs remaining in Alberta Region.

As long as these tubs are still in place, The Virox™ cleaning and disinfection protocol is provided as a guideline for use on existing jetted hydrotherapy tubs. The Virox Hydrotherapy Tub Disinfectant® and other related products can be accessed through the Drug Distribution Centre (DDC).

http://www.virox.com/files_docs/content/pdf/msds/HydrotherapyPlusProtocolCanada_000.pdf



January 2017 68

Cleaning and Disinfection Protocol for

Hydrotherapy Tubs

This document has been developed in accordance with current applicable infection control and regulatory

guidelines. It is intended for use as a guideline only. At no time should this document replace existing

documents established by the facility unless written permission has been obtained from the responsible

facility manager.

The overall goal of infection prevention practices is to eliminate the risk of the transmission of pathogens between patients and between patients and the health care worker. The following recommendations should be implemented when cleaning and disinfecting. These procedures follow the Spaulding Classification of the level of care required for surfaces and instruments. Environmental surfaces and non-critical equipment are surfaces or equipment that come in contact with intact skin but not mucous membranes. Intact skin acts as an effective barrier to most microorganisms. There is virtually no risk of transmitting infectious agents to patients via non-critical items; however, these items could potentially contribute to secondary transmission by contaminated hands for Health Care Workers or by contact with medical equipment that will subsequently come in contact with patients.

Although microorganisms are ubiquitous in health care settings, inanimate materials are seldom responsible for the direct spread of infections. Cleaning and maintenance prevent the build-up of soil, dust or other foreign material that can harbour pathogens and support their growth. Daily cleaning and disinfection of environmental surfaces and patient care equipment are important in limiting the transmission of organisms. Appropriate personal protection should be taken for those responsible for the decontamination of a room or area.

1. Disposable gloves. Gloves should be changed as required, i.e., when torn, when hands become wet inside the glove or when moving between patient rooms.

2. Household gloves can be worn, but they must be discarded when the cleaning is complete. 3. Protective Eye wear (goggles, face shield or mask with eye protection) should be worn when

mixing concentrates. 4. Masks (surgical or procedural masks sufficient) should be used when working with concentrates. 5. Gowns should be used when working with concentrates.

PREFACE

PREPARATION

PROTECTIVE BARRIERS



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Accelerated Hydrogen Peroxide (AHP) 4% Concentrate Hydrotherapy Disinfectant (sold as 4% Accel

Hydrotherapy+ Concentrate™)

Determine method for the Dispensing of solution - 4% AHP Concentrate at a ratio of 1:16 for purging or disinfecting, 1:128 for sanitizing.

Note: Accelerated Hydrogen Peroxide Surface disinfectants (Accel TB Ready to Use™) can be used on hand contact surfaces of tubs where a greater degree of care is required or desired.

HYDROTHERAPY STANDARD DILUTIONS

RATIO PER US GALLON PER 15 L WATER

1:128 1 OZ. 128 ml

1:16 8 OZ. 960 ml

AHP Hydrotherapy products are based upon Accelerated Hydrogen Peroxide™ – and carries a Broad-Spectrum Sanitizing claim against vegetative bacteria, and a Bactericidal claim against gram negative and gram positive vegetative bacteria.

Dilute AHP Hydrotherapy+ in the tub that is to be cleaned and disinfected. Turn jets on to circulate. Turn off jets and allow AHP Hydrotherapy+ solution to sit in the lines. Clean and disinfect the surfaces of the hydrotherapy tub using a cloth, sponge or brush. Turn jets on to circulate a second time. Drain tub and refill with clean water. Turn jets on to rinse and drain tub.

1. Gather all equipment, cleaning solutions and materials required to disinfect and clean the tub.

2. For jetted tubs, fill the tub with cool water to above all of the water jets. Measure the volume of the water.

Add AHP Hydrotherapy+ at 1:16 (refer to dilution table).

3. To reduce the generation of foam, add Dow Corning Antifoam (Antifoam 1410 or Antifoam C) at the rate

of 5% of the amount of Accel Hydrotherapy+. Antifoam is available through most retailers of carpet care

and cleaning products.

4. Turn on the jets and circulate for 5 minutes.

5. Turn off jets and allow Hydrotherapy+ to sit in the lines for another 5 minutes.

6. Turn on jets and circulate for another 5 minutes.

7. Drain Tub.

8. Refill tub with cool water to above the jet lines.

9. Turn on jets to circulate and rinse for 30 seconds.

10. Turn off jets and drain.

* Biofilm strength can vary dramatically. Purging may have to be repeated depending upon the level of contamination and/or age of the tub.

PRODUCTS

PRODUCT GERMICIDAL EFFICACY

SUMMARY OF PROCEDURES

Recommended Procedures for Initial Purging When Biofilm* is Known to be Present:



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Recommended Procedures for Disinfecting and Prevention of Biofilm Formation:

1. Gather all equipment, cleaning solutions and materials required to disinfect and clean the tub.

2. For jetted tubs, fill the tub with cool water to above the water jets. Measure the volume of the water. Add

AHP Hydrotherapy+ at 1:16 (Refer to Dilution table).

3. Turn on the jets until they circulate solution. To reduce the generation of foam, add Dow Corning

Antifoam (Antifoam 1410 or Antifoam) at the rate of 5% of the amount of Accel Hydrotherapy+.

Antifoam is available through most retailers of carpet care and cleaning products.

4. Turn jets off and allow Hydrotherapy+ to sit in the lines for 5 minutes.

5. Surfaces inside tub can be cleaned with a brush.

6. Turn on jets until they circulate solution.

7. Drain Tub

8. Refill the tub to above the jets.

9. Turn on jets for 5-30 seconds to rinse

10. Drain Tub

1. Gather all equipment, cleaning solutions and materials required to sanitize and clean the tub.

2. For jetted tubs, fill the tub with cool water to above all of the water jets. Measure the volume of the water.

Add AHP Hydrotherapy+ at 1:16 (refer to dilution table).

3. Turn on the jets until they circulate solution. To reduce the generation of foam, add Dow Corning

Antifoam (Antifoam 1410 or Antifoam) at the rate of 5% of the amount of Accel Hydrotherapy+.

Antifoam is available through most retailers of carpet care and cleaning products.

4. Turn jets off and allow Hydrotherapy+ to sit in the lines for 30 seconds

5. Surfaces inside tub can be cleaned with a brush.

6. Turn on jets until they circulate solution.

7. Drain Tub

8. Refill the tub to above the jets.

9. Turn on jets for 5-30 seconds to rinse

The Accelerated Hydrogen Peroxide Test Strip (Part No. AHP500) can be used for confirmatory testing when the 1:16 dilution is used and disinfection required. The AHP100 Test Strips can be used for confirmatory testing of the 1:128 dilution when sanitizing is desired. These strips are easy to use dip-and-read reagents strips for a pass or fail determination of the hydrogen peroxide concentration. 1. Remove a test strip and immediately close the container. 2. Dip the test strip into the diluted AHP solution to be tested for 1-second ensuring that the reaction

zone is completely wetted. 3. Remove the test strip and shake of excess liquid. 4. Wait for required time period (AHP500 – 120 seconds; AHP100 – 30 seconds) then compare the

reaction zone with the color scale. 5. The in use concentrations will be: 2500ppm = 1:16; 315ppm – 1:128.

Provincial Infectious Diseases Advisory Committee, Best Practices for Cleaning, Disinfection and Sterilization in All

Healthcare Settings, 2006

Public Health Agency of Canada, Infection Control Guidelines for Hand Washing, Cleaning, Disinfection and Sterilization in Healthcare, Volume 24S8, 1998

Recommended Procedures for Sanitizing and Regular Maintenance between Low Risk Bathers:

Instructions for Confirmatory Testing of 4% AHP Hydrotherapy+ Concentrate

References:



January 2017 71

Appendix 7: FNIHB Alberta Region: Single Use Policy, January 14, 2014

Infection Prevention and Control Best Practice Guideline for Medical and Dental Equipment and Devices.

Statement When delivering medical and dental services, single use equipment is best practice. If single use equipment is not available, multi-client reusable equipment can be used as outlined in the FNIHB Reprocessing Reusable Medical and Dental Equipment Policy and Protocol, 2011. Rationale Use of disposable instruments eliminates the need for reprocessing and minimizes the risk of exposure, injury and prevents transmission of micro-organisms to clients and personnel3.

Guideline Details

“Single use instruments” are defined as equipment designated by the manufacturer as one time use only and are not designed to be reprocessed or used on multiple clients. Single use instruments, when available for semi-critical and critical procedures, are the preferred instruments of choice as they can be discarded after use, therefore eliminating the need for reprocessing. “Multiple client reusable equipment” is defined as equipment that can be reused on several clients when properly reprocessed according to its classification for use. All reusable equipment must be reprocessed according to its defined classification as per the FNIHB Reprocessing Reusable Medical and Dental Equipment Policy and Protocol, 2011. Reusable Equipment is classified into categories based on the risk of infection involved with its use5. There are three categories of device classifications each with its prescribed level of reprocessing requirements as summarized in the chart below.



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Table 5: Classification of Equipment and Required Level of Reprocessing

Classification of Equipment

Examples of Equipment Minimum Level of Reprocessing Required:

Noncritical equipment: Equipment that touches only intact skin and not mucous membranes, or does not directly touch the client.

Bed pans, urinals, commodes

Stethoscopes

Blood pressure cuffs

Oximeters

Glucose meters

Electronic thermometers

ECG machines/leads/cups etc.

Baby scales

Environmental surfaces (e.g.wheelchairs, beds)

Examination tables

Dental chairs

Hand mirrors

Cleaning* followed by Low-Level Disinfection

Low-level disinfectants kill most vegetative bacteria and some fungi as well as enveloped (lipid) viruses. Low-level disinfectants do not kill mycobacteria or bacterial spores. Low-level disinfection is required when processing noncritical equipment or some environmental surfaces.

Semi critical equipment: Equipment that comes in contact with non-intact skin or mucous membranes but does not penetrate them.

Specula - nasal, anal, vaginal (disposable equipment is strongly recommended)

Diaphragm fitting rings

Alligator forceps

Ear cleaning equipment, ear syringe nozzles, ear curettes, otoscope tips

Fingernail care equipment used on multiple clients

Nebulizer cups

CPR face masks

Cleaning* followed by High-Level Disinfection

High-level disinfection destroys vegetative bacteria, mycobacteria, fungi and enveloped (lipid) and non-enveloped (non-lipid) viruses, but not necessarily bacterial spores.

Critical equipment: Equipment that enters sterile tissues, including the vascular system.

Surgical instruments

Foot care equipment

Fish hook cutters

Dental equipment including dental hand pieces

Cleaning* followed by Sterilization

Sterilization results in the destruction of all forms of microbial life including bacteria, viruses, spores and fungi. Steam sterilization or liquid chemical sterilization may be appropriate.

Applicability This guideline is a directive for FNIHB Regional Nursing staff, Home Care, and Dental programs for the services provided within their respective program areas and within the community setting. External providers such as private practitioners, dentists, etc., are required to follow guidelines set out by their governing professional bodies but may conform to this infection control guideline as a minimum standard. In the absence of infection control guidelines, these guidelines may be used by staff as a best practice guideline.

Compliance/Implications

Programs are responsible to develop policies according to these guidelines. Policies should be inclusive of requirements for equipment storage, disposal as well as risks of misuse.



January 2017 73

References 1. Alberta Health. 2012. Standards for Cleaning, Disinfection and Sterilization of Reusable Medical Devices

for Health Care Facilities and Settings. 2. Public Health Agency of Canada. 2013. Routine Practices and Additional Precautions for Preventing the

Transmission of Infection in Healthcare Settings 3. Alberta Health Services,2013. Infection Prevention and Control IPC Best Practise Guideline for Foot Care

Devices. 4. Health Canada, First Nation and Inuit Health Branch.2011. Reprocessing Reusable Medical and Dental

Equipment Policy and Protocol. 5. Ontario Ministry of Health and Long-Term Care, Provincial Infectious Diseases Advisory Committee.2013.

Best Practices for Cleaning, Disinfection and Sterilization of Medical Equipment Devices in all Health Care Settings.

6. Canadian Standards Association. 2008.Z314.8 Decontamination of Reusable Medical Devices

http://www.health.alberta.ca/documents/IPC-Medical-Device-Cleaning-2012.pdf

http://www.health.alberta.ca/documents/IPC-Medical-Device-Cleaning-2012.pdf



http://www.albertahealthservices.ca/assets/healthinfo/ipc/hi-ipc-footcare-bpg.pdf

http://www.albertahealthservices.ca/assets/healthinfo/ipc/hi-ipc-footcare-bpg.pdf

http://www.publichealthontario.ca/en/eRepository/PIDAC_Cleaning_Disinfection_and_Sterilization_2013.pdf




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Appendix 8: Providing Care in Bed Bug Infested Residences If entering an environment that is known or suspected to be infested:

Schedule visits for the end of the day

Conduct a risk assessment of the situation

Use Personal Protective Equipment based on PCRA

Shoe covers should be worn routinely on home visits and discarded upon exiting o Alternatives may include dedicated shoes that can be changed into at the time of

entry, stored in a sealed bag upon exit and that can be easily washed and dried in a dryer

Clothing: nursing uniform or light coloured clothing to allow for ease of identification if in contact with bed bugs; avoid cuffed pants or pant legs that touch the ground

Only bring items that are required for service delivery into the home. Carry these supplies in a sealed bag and only open when retrieving supplies

o Do not bring unnecessary equipment or supplies into the home If this is not possible and the nursing bag must be brought into the house,

consider using a disposable barrier for the bag to rest on or placing it into a protective sealed case or disposable bag

Leave personal belongings in the vehicle, i.e.) coats, bags.

Meet clients in settings of the home that are less likely to be infested, i.e.) avoid providing service in beds, sleep areas or on upholstered furnishings

○ Create a controlled environment through use of barriers

Do not sit or place personal belongings on the floor or upholstered surfaces without a barrier; o try to place on smooth, easily cleanable surfaces like a kitchen table or

chair

Anything that is removed in the home to provide care and must be returned to the health centre should be place in a sealed bag and inspected before returned

o i.e. blood pressure cuff, client files

Dispose of all barriers upon exiting the home

If garbage disposal is not available at time of exit, place all outer coverings and PPE into a sealed bag for later disposal

o A plastic sealed container may be used in the vehicle to house items for return to health centre

Inspect your clothing and belongings upon exiting the home for any noticeable signs of “hitchhikers”

Before Return to the Health Centre or home:

Before entering your home it is recommended that all clothing including shoes, are removed and placed in a sealed bag followed by placing in a hot dryer for 30 minutes. Dispose of any garbage before entering your home.



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Reporting an Infestation: If bed bugs are found, retain one in a sealed container for identification purposes,

otherwise adult bugs can be killed using alcohol or mechanical force. If during your

home visit, evidence of infestation is visible:

Advise and educate clients of the potential problem being mindful that pest infestation is a sensitive subject matter

Advise your immediate supervisor

Each community may have different response plans however the health director may advise the local public works or housing departments

If pests are found in a community facility (school, daycare, community hall) or in a food

service area, the community’s Environmental Health Officer should be notified.

Resources:

Environmental Public Health Officers, Health Canada FNIHB

Alberta Health Services. Bedbug Management Protocols for Health Care Workers.

http://www.albertahealthservices.ca/assets/healthinfo/ipc/hi-ipc-bedbug-management-protocol-hcw.pdf



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References 1. Canadian Committee on Antibiotic Resistance. Infection Prevention and Control

Best Practices for Long Term Care, Home and Community Care including Health Care Offices and Ambulatory Clinics; 2007.

2. Public Health Agency Of Canada, Routine Practices and Additional Precautions for Preventing the transmission of Infection in Healthcare Settings, 2012. http://publications.gc.ca/collections/collection_2013/aspc-phac/HP40-83-2013-eng.pdf

3. Jarvis W, editor. Bennet and Brachman’s Hospital Infections. 5th ed. Philadelphia: Lippincott & Wilkins; 2007.

4. Association for Professionals in Infection Control and Epidemiology, editor. APIC Text of Infection Control and Epidemiology. 2nd ed.; 2005

5. Public Health Ontario. Provincial Infectious Diseases Advisory Committee, Infection Prevention and Control for Clinical Office Practice, June 2013. http://www.publichealthontario.ca/en/eRepository/IPAC_Clinical_Office_Practice_2013.pdf

6. Public Health Agency of Canada, Hand Hygiene Practices in Health Care Settings, 2012 http://publications.gc.ca/collections/collection_2012/aspc-phac/HP40-74-2012-eng.pdf

7. Public Health Agency of Canada, Canadian Immunization Guide. Evergreen edition. http://www.phac-aspc.gc.ca/publicat/cig-gci/index-eng.php

8. Public Health Ontario. Provincial Infectious Diseases Advisory Committee: Routine Practices and Additional Precautions in all Health Care Settings, 2012. http://www.publichealthontario.ca/en/eRepository/RPAP_All_HealthCare_Settings_Eng2012.pdf

9. Public Health Agency of Canada. Guidance: Infection Prevention and Control Measures for Health Care Workers in Acute and Long Term Care Settings: Seasonal Influenza, 2010. http://www.phac-aspc.gc.ca/nois-sinp/guide/pdf/ac-sa-eng.pdf

10. Public Health Agency of Canada, Laboratory Safety Office, Transportation of Dangerous Goods Nursing Manual, 2014.

11. Nunavut Department of Health, Infection Prevention and Control Manual, 2012. http://www.gov.nu.ca/health/information/infection-prevention-and-control

12. Public Health Ontario. Provincial Infectious Diseases Advisory Committee: Best Practices for Environmental Cleaning for Prevention and Control of Infections in All Health Care Settings, 2nd edition, 2012. http://www.publichealthontario.ca/en/eRepository/Best_Practices_Environmental_Cleaning_2012.pdf

13. Public Health Ontario. Provincial Infectious Diseases Advisory Committee: Best Practices for Cleaning, Disinfection and Sterilization of Medical Equipment/Devices in All Health Care Settings, 3rd edition, 2013. http://www.publichealthontario.ca/en/eRepository/PIDAC_Cleaning_Disinfection_and_Sterilization_2013.pdf


http://www.publichealthontario.ca/en/eRepository/IPAC_Clinical_Office_Practice_2013.pdf


http://www.phac-aspc.gc.ca/publicat/cig-gci/index-eng.php

http://www.publichealthontario.ca/en/eRepository/RPAP_All_HealthCare_Settings_Eng2012.pdf

http://www.phac-aspc.gc.ca/nois-sinp/guide/pdf/ac-sa-eng.pdf

http://www.gov.nu.ca/health/information/infection-prevention-and-control

http://www.publichealthontario.ca/en/eRepository/Best_Practices_Environmental_Cleaning_2012.pdf





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14. Public Health Agency of Canada: Guidance: Infection Prevention and Control Measures for Health Care Workers in Acute and Long Term Care Settings: Seasonal Influenza, 2010. http://www.phac-aspc.gc.ca/nois-sinp/guide/pdf/ac-sa-eng.pdf

15. Fallis P. Infection Prevention and Control in Office-based Health Care and Allied Services. Canadian Standards Association; 2004

16. Janecek, C., Manikowske, L., & Bromel, M. Sanitation of Low Temperature Home Laundry.

17. Nordstrom, J. Evaluation of the Occurrence and Risk of Microbes in Laundry and Laundry Associated Surfaces, in Department of Soil, Water and Environmental science. 2009. University of Arizona.

18. Alberta Health. MRSA Guidelines. 2007



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